Provider Demographics
NPI:1881790087
Name:WETHERBEE, ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:WETHERBEE
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 1:530 1ST AVE
Mailing Address - Street 2:SUITE 4C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-7243
Mailing Address - Fax:212-263-5899
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SUITE 4C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-7243
Practice Address - Fax:212-263-5899
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118155-1207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM139168OtherUNITED HEALTHCARE
NY00718709Medicaid
NY970611OtherBLUE CROSS
NY124439OtherAETNA
NYNP1235OtherOXFORD
NY970611OtherBLUE CROSS
NY124439OtherAETNA