Provider Demographics
NPI:1942303029
Name:ROTH, CARL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:14136-1452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:NY
Practice Address - Zip Code:14136-1452
Practice Address - Country:US
Practice Address - Phone:716-934-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200012207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110113219OtherRAILROAD MEDCARE
NY01576076Medicaid
NY01576076Medicaid
NY110113219OtherRAILROAD MEDCARE
NY37085HMedicare ID - Type Unspecified