Provider Demographics
NPI:1467606392
Name:ROTH, MARY DEBORAH (RDLD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DEBORAH
Last Name:ROTH
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 N BALLAS RD STE 216B
Mailing Address - Street 2:STE 216B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-996-4351
Mailing Address - Fax:314-996-4591
Practice Address - Street 1:3009 N BALLAS RD STE 216B
Practice Address - Street 2:STE 216B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-996-4351
Practice Address - Fax:314-996-4591
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001016361133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000081550Medicare PIN