Provider Demographics
NPI:1609803410
Name:ROTH, ELIZABETH R (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:WHA, YAWKEY 4B
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-6700
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WHA, YAWKEY 4B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA215929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0179272OtherBLUE CROSS
MA0027643OtherNEIGHBORHOOD HEATLH
MA215929OtherTUFTS
MA693127OtherHARVARD PILGRIM
MAG21027Medicare UPIN
MA0179272OtherBLUE CROSS