Provider Demographics
NPI:1750448452
Name:ROTH, LARRY H (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:H
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:521 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4191
Mailing Address - Country:US
Mailing Address - Phone:617-923-4400
Mailing Address - Fax:617-926-4549
Practice Address - Street 1:521 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4191
Practice Address - Country:US
Practice Address - Phone:617-923-4400
Practice Address - Fax:617-926-4549
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA40273207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2068672Medicaid
MAB95240Medicare UPIN
MAC04820Medicare ID - Type Unspecified