Provider Demographics
NPI:1205873924
Name:ROTH, DOUGLAS A (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:110 S BEDFORD RD
Mailing Address - Street 2:MOUNT KISCO MEDICAL GROUP, PC
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3446
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-242-2909
Practice Address - Street 1:90 S BEDFORD RD
Practice Address - Street 2:MOUNT KISCO MEDICAL GROUP, PC
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3412
Practice Address - Country:US
Practice Address - Phone:914-241-1050
Practice Address - Fax:914-242-2909
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-07-22
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Provider Licenses
StateLicense IDTaxonomies
NY186557208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01921351Medicaid
NYG89601Medicare UPIN
NY01921351Medicaid