Healthcare Provider Details

I. General information

NPI: 1134706328
Provider Name (Legal Business Name): CORY ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE STE 2703
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE STE 2703
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2419
  • Fax: 551-996-3962
Mailing address:
  • Phone: 551-996-2419
  • Fax: 551-996-3962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA13209100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: