Provider Demographics
NPI:1790979920
Name:ROH, MARY SUN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUN
Last Name:ROH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15492 E PRENTICE DR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4267
Mailing Address - Country:US
Mailing Address - Phone:817-422-7155
Mailing Address - Fax:
Practice Address - Street 1:15492 E PRENTICE DR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-4267
Practice Address - Country:US
Practice Address - Phone:817-422-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58214208000000X
CODR0052245208000000X
TXM4930208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty