Provider Demographics
NPI:1689625030
Name:ROTY, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:ROTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 W KING ST
Mailing Address - Street 2:PO BOX 456
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2120
Mailing Address - Country:US
Mailing Address - Phone:989-729-6353
Mailing Address - Fax:
Practice Address - Street 1:8750 MONROE RD
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:MI
Practice Address - Zip Code:48429-1000
Practice Address - Country:US
Practice Address - Phone:989-729-6353
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301025299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26670Medicare UPIN
MIN53550023Medicare ID - Type Unspecified