Healthcare Provider Details

I. General information

NPI: 1033366380
Provider Name (Legal Business Name): DANIEL ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 15TH AVE
BROOKLYN NY
11219-3997
US

IV. Provider business mailing address

5211 15TH AVE.
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 718-851-7444
  • Fax: 718-851-9594
Mailing address:
  • Phone: 718-851-7444
  • Fax: 718-851-9594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number263035
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: