Provider Demographics
NPI:1831241264
Name:RILEY, ROTH LEON (MD)
Entity type:Individual
Prefix:MR
First Name:ROTH
Middle Name:LEON
Last Name:RILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23-08 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-794-4500
Mailing Address - Fax:229-271-3839
Practice Address - Street 1:23-08 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-794-4500
Practice Address - Fax:229-271-3839
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA025656207Q00000X
NJ25MA09551100207Q00000X
GA025656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA025656OtherGA LICENSE
GA000280486BMedicaid
GA00280486BMedicaid
GA000280486BMedicaid