Provider Demographics
NPI:1649266081
Name:ROTH, ALLAN MARK (PT)
Entity type:Individual
Prefix:MR
First Name:ALLAN
Middle Name:MARK
Last Name:ROTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07653-0691
Mailing Address - Country:US
Mailing Address - Phone:201-225-9222
Mailing Address - Fax:202-225-9223
Practice Address - Street 1:600 WINTERS AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3904
Practice Address - Country:US
Practice Address - Phone:201-225-9222
Practice Address - Fax:201-225-9223
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA04933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
034140NSZMedicare ID - Type Unspecified