Provider Demographics
NPI:1023080645
Name:ROETZER, GLORIA (MD)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:
Last Name:ROETZER
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 1:2730 UNION ROAD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227
Mailing Address - Country:US
Mailing Address - Phone:716-332-7377
Mailing Address - Fax:888-452-3065
Practice Address - Street 1:2730 UNION ROAD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227
Practice Address - Country:US
Practice Address - Phone:716-332-7377
Practice Address - Fax:716-568-8228
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206060208000000X
NY206060-12080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01747066Medicaid