Healthcare Provider Details

I. General information

NPI: 1205745635
Provider Name (Legal Business Name): MATTHEW JACOB ROTH LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 WESTCHESTER AVE STE 110
BRONX NY
10461-3585
US

IV. Provider business mailing address

133 LINCOLN AVE APT 3
BRONX NY
10454-4432
US

V. Phone/Fax

Practice location:
  • Phone: 929-303-1666
  • Fax:
Mailing address:
  • Phone: 929-303-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number007969
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: