Provider Demographics
NPI:1346212057
Name:ROTH, DOUGLAS M (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1 DIAMOND HILL RD
Mailing Address - Street 2:SUMMIT MEDICAL GROUP
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:973-376-0357
Practice Address - Street 1:85 WOODLAND RD
Practice Address - Street 2:SUMMIT MEDICAL GROUP
Practice Address - City:SHORT HILLS
Practice Address - State:NJ
Practice Address - Zip Code:07078-2449
Practice Address - Country:US
Practice Address - Phone:973-315-9076
Practice Address - Fax:973-376-0357
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2019-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMB53578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE80584Medicare UPIN
NJ653607BSDMedicare ID - Type Unspecified