Provider Demographics
NPI:1891836813
Name:ROTH, SHELDON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:
Last Name:ROTH
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 1:1765 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1402
Mailing Address - Country:US
Mailing Address - Phone:617-332-6150
Mailing Address - Fax:617-527-6677
Practice Address - Street 1:1765 BEACON ST
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-1402
Practice Address - Country:US
Practice Address - Phone:617-332-6150
Practice Address - Fax:617-527-6677
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA298752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY02196Medicare ID - Type UnspecifiedINDIVIDUALPROVIDER NUMBER
MAB99516Medicare UPIN