Provider Demographics
NPI:1700879707
Name:ADAMS, TANYA ROTH (DO)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:ROTH
Last Name:ADAMS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2918
Mailing Address - Country:US
Mailing Address - Phone:631-941-4480
Mailing Address - Fax:631-941-4480
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2918
Practice Address - Country:US
Practice Address - Phone:631-941-4480
Practice Address - Fax:631-941-4480
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY227867-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3128E1Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER
NYI01001Medicare UPIN
NYWVN231Medicare ID - Type UnspecifiedGROUP ID NUMBER