Provider Demographics
NPI:1538145644
Name:ROTH, JUDITH G
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:G
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 BLACKHEATH RD
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4840
Mailing Address - Country:US
Mailing Address - Phone:516-431-2636
Mailing Address - Fax:516-432-5841
Practice Address - Street 1:164 BLACKHEATH RD
Practice Address - Street 2:
Practice Address - City:LIDO BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4840
Practice Address - Country:US
Practice Address - Phone:516-431-2636
Practice Address - Fax:516-432-5841
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXOO4297111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
X27281Medicare PIN