Provider Demographics
NPI:1497083307
Name:ROTH, DANIEL (MPT, MS ED, CSCS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:MPT, MS ED, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W 110TH ST
Mailing Address - Street 2:APT 19H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2408
Mailing Address - Country:US
Mailing Address - Phone:917-774-9997
Mailing Address - Fax:917-599-0457
Practice Address - Street 1:424 W 110TH ST
Practice Address - Street 2:APT 19H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2408
Practice Address - Country:US
Practice Address - Phone:917-774-9997
Practice Address - Fax:917-599-0457
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0287971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist