Provider Demographics
NPI:1598775884
Name:ROTH, MALCOLM ZACHARY (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:ZACHARY
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD, FACS
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Mailing Address - Street 1:925 49TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2923
Mailing Address - Country:US
Mailing Address - Phone:718-283-7022
Mailing Address - Fax:718-283-8123
Practice Address - Street 1:925 49TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2923
Practice Address - Country:US
Practice Address - Phone:718-283-7022
Practice Address - Fax:718-283-8123
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1580572082S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01094444Medicaid
0015625OtherGHI
26E721OtherBCBS
NY01094444Medicaid
A61699Medicare UPIN