Provider Demographics
NPI:1679527956
Name:ROTH, CHARLES B
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42084 STATE HIGHWAY 28
Mailing Address - Street 2:
Mailing Address - City:MARGARETVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12455-2820
Mailing Address - Country:US
Mailing Address - Phone:845-586-2631
Mailing Address - Fax:845-586-2976
Practice Address - Street 1:42084 STATE HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:MARGARETVILLE
Practice Address - State:NY
Practice Address - Zip Code:12455-2820
Practice Address - Country:US
Practice Address - Phone:845-586-2631
Practice Address - Fax:845-586-2976
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS62730Medicare UPIN
NY0F0781Medicare ID - Type Unspecified