Healthcare Provider Details

I. General information

NPI: 1902856396
Provider Name (Legal Business Name): JAMES CHARLES ROOT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 YORK AVE BOX 140 F1302
NEW YORK NY
10021-4805
US

IV. Provider business mailing address

1300 YORK AVE BOX 140 F1302
NEW YORK NY
10021-4805
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-5936
  • Fax:
Mailing address:
  • Phone: 212-746-5936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number68015884
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: