Provider Demographics
NPI:1457014250
Name:ROTH, MELISSA JEAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 VETERANS HWY
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3046
Mailing Address - Country:US
Mailing Address - Phone:631-366-3876
Mailing Address - Fax:
Practice Address - Street 1:1363 VETERANS HWY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3046
Practice Address - Country:US
Practice Address - Phone:631-366-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist