Healthcare Provider Details

I. General information

NPI: 1396352274
Provider Name (Legal Business Name): MARK ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NATIONAL CANCER INSTITUTE BLDG 10, ROOM 2S235K
BETHESDA MD
20892-0001
US

IV. Provider business mailing address

6118 OFFUTT RD
CHEVY CHASE MD
20815-5427
US

V. Phone/Fax

Practice location:
  • Phone: 301-480-8067
  • Fax:
Mailing address:
  • Phone: 240-468-3915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberD0046369
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: