Provider Demographics
NPI:1477559086
Name:ROTH, DIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-5009
Mailing Address - Country:US
Mailing Address - Phone:718-972-2700
Mailing Address - Fax:718-532-1724
Practice Address - Street 1:5925 15TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5009
Practice Address - Country:US
Practice Address - Phone:718-972-2700
Practice Address - Fax:718-532-1724
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2018-03-30
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
NY225761-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY601D21Medicare ID - Type Unspecified
NYH77269Medicare UPIN