Provider Demographics
NPI:1801881677
Name:ROETHEL, LINDA (MD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:ROETHEL
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 1:1 HEALTHY WAY
Mailing Address - Street 2:ATTN: PHYSICIAN BILLING DEPT
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1551
Mailing Address - Country:US
Mailing Address - Phone:516-255-1600
Mailing Address - Fax:516-255-4672
Practice Address - Street 1:196 MERRICK RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1420
Practice Address - Country:US
Practice Address - Phone:516-255-1616
Practice Address - Fax:516-255-4672
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01425149Medicaid
NY184344OtherHIP
NYGP160OtherOXFORD
NY000000071571OtherGHI HMO
NY5903664OtherGHI PPO
NY0D4451OtherBCBS
NY5022479OtherAETNA PPO
NY5782299OtherCIGNA
NYAA71640OtherMDNY
NY1000021935OtherAFFINITY
NY2C9292OtherHEALTHNET
NY519648OtherAETNA HMO
NY71H211Medicare ID - Type Unspecified
NYAA71640OtherMDNY