Provider Demographics
NPI:1730116807
Name:ROTH, LISA CAREN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CAREN
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10 UNION AVE
Mailing Address - Street 2:SUITE 11A&B
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3397
Mailing Address - Country:US
Mailing Address - Phone:516-599-6910
Mailing Address - Fax:516-612-3402
Practice Address - Street 1:10 UNION AVE
Practice Address - Street 2:SUITE11A&B
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3397
Practice Address - Country:US
Practice Address - Phone:516-599-6910
Practice Address - Fax:516-612-3402
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2009-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY189734207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF48305Medicare UPIN
NY27H191Medicare PIN