Healthcare Provider Details

I. General information

NPI: 1679527956
Provider Name (Legal Business Name): CHARLES B ROTH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42084 STATE HIGHWAY 28
MARGARETVILLE NY
12455-2820
US

IV. Provider business mailing address

42084 STATE HIGHWAY 28
MARGARETVILLE NY
12455-2820
US

V. Phone/Fax

Practice location:
  • Phone: 845-586-2631
  • Fax: 845-586-2976
Mailing address:
  • Phone: 845-586-2631
  • Fax: 845-586-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000212
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: