Provider Demographics
NPI:1508880592
Name:ROTH, SCOTT LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LAWRENCE
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CRESCENT LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1528
Mailing Address - Country:US
Mailing Address - Phone:516-805-3994
Mailing Address - Fax:866-524-1562
Practice Address - Street 1:2 CRESCENT LN
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1528
Practice Address - Country:US
Practice Address - Phone:516-805-3994
Practice Address - Fax:866-524-1562
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172466207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01395353Medicaid
NY01395353Medicaid
NYF33464Medicare UPIN