Healthcare Provider Details

I. General information

NPI: 1801881677
Provider Name (Legal Business Name): LINDA ROETHEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 MERRICK RD
OCEANSIDE NY
11572-1420
US

IV. Provider business mailing address

1 HEALTHY WAY ATTN: PHYSICIAN BILLING DEPT
OCEANSIDE NY
11572-1551
US

V. Phone/Fax

Practice location:
  • Phone: 516-255-1616
  • Fax: 516-255-4672
Mailing address:
  • Phone: 516-255-1600
  • Fax: 516-255-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number184344
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: