Healthcare Provider Details

I. General information

NPI: 1790979920
Provider Name (Legal Business Name): MARY SUN ROH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15492 E PRENTICE DR
CENTENNIAL CO
80015-4267
US

IV. Provider business mailing address

15492 E PRENTICE DR
CENTENNIAL CO
80015-4267
US

V. Phone/Fax

Practice location:
  • Phone: 817-422-7155
  • Fax:
Mailing address:
  • Phone: 817-422-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG58214
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR0052245
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM4930
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: