1346830395 NPI number — ALEXANDRA JADE ROTH

Table of content: ALEXANDRA JADE ROTH (NPI 1346830395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346830395 NPI number — ALEXANDRA JADE ROTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
ALEXANDRA
Provider Middle Name:
JADE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346830395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1719 HIMROD ST APT 2R
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGEWOOD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11385-1479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-964-8034
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
162 COURT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201-6445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-964-8034
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 221700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)