Healthcare Provider Details

I. General information

NPI: 1447423025
Provider Name (Legal Business Name): MIRIAM DEBORAH ROTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 EASTCHESTER RD
BRONX NY
10461-2301
US

IV. Provider business mailing address

1825 EASTCHESTER RD
BRONX NY
10461-2301
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-2767
  • Fax:
Mailing address:
  • Phone: 718-904-2767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number212-612
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: