Provider Demographics
NPI:1588626451
Name:ROTH, IRA MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:MARK
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:110 E 59TH ST
Mailing Address - Street 2:SUITE 8A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1304
Mailing Address - Country:US
Mailing Address - Phone:212-288-2432
Mailing Address - Fax:212-434-6169
Practice Address - Street 1:110 E 59TH ST
Practice Address - Street 2:SUITE 8A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1304
Practice Address - Country:US
Practice Address - Phone:212-288-2432
Practice Address - Fax:212-434-6169
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY156478207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA65257Medicare UPIN
NY98D441Medicare ID - Type Unspecified