Healthcare Provider Details

I. General information

NPI: 1598775884
Provider Name (Legal Business Name): MALCOLM ZACHARY ROTH MD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 49TH ST 1ST FLOOR
BROOKLYN NY
11219-2923
US

IV. Provider business mailing address

925 49TH ST 1ST FLOOR
BROOKLYN NY
11219-2923
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-7022
  • Fax: 718-283-8123
Mailing address:
  • Phone: 718-283-7022
  • Fax: 718-283-8123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number158057
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number158057
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: