Provider Demographics
NPI:1538140785
Name:ROTH, ROBERT G (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
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 1:120 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2604
Mailing Address - Country:US
Mailing Address - Phone:631-928-1222
Mailing Address - Fax:631-928-8605
Practice Address - Street 1:120 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2604
Practice Address - Country:US
Practice Address - Phone:631-928-1222
Practice Address - Fax:631-928-8605
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0819132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00390414Medicaid
NYRR03788410Medicare ID - Type Unspecified
NY378841Medicare PIN
NYC09415Medicare UPIN