Provider Demographics
NPI:1174805725
Name:ROTH, JENNIFER LOBBAN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOBBAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 WAYNE AVE
Mailing Address - Street 2:APT 13H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 WAYNE AVE
Practice Address - Street 2:APT 13H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2510
Practice Address - Country:US
Practice Address - Phone:305-979-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X.207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine