Provider Demographics
NPI:1437157229
Name:ROTH, GARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:ROTH
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Gender:M
Credentials:DO
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Mailing Address - Street 1:405 W GREENLAWN AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-2898
Mailing Address - Country:US
Mailing Address - Phone:517-483-7543
Mailing Address - Fax:517-483-4862
Practice Address - Street 1:405 W GREENLAWN AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2898
Practice Address - Country:US
Practice Address - Phone:517-483-4780
Practice Address - Fax:517-483-4862
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2010-07-01
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Provider Licenses
StateLicense IDTaxonomies
MI5101008743208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437157229Medicaid
MI1437157229Medicaid
MI0P27070003Medicare PIN