Provider Demographics
NPI:1710031513
Name:ROTH, TRACY (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4153
Mailing Address - Country:US
Mailing Address - Phone:718-768-1616
Mailing Address - Fax:718-788-8274
Practice Address - Street 1:348 13TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-5004
Practice Address - Country:US
Practice Address - Phone:718-788-2461
Practice Address - Fax:718-788-8274
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2025502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry