Provider Demographics
NPI:1780028928
Name:ROTH, MARY J (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:ROTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:HAWKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:47 WIDEFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-2126
Mailing Address - Country:US
Mailing Address - Phone:719-282-6100
Mailing Address - Fax:719-282-6106
Practice Address - Street 1:47 WIDEFIELD BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-2126
Practice Address - Country:US
Practice Address - Phone:719-282-6100
Practice Address - Fax:719-282-6106
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered