Provider Demographics
NPI:1861795221
Name:LEON ROTH M.D. P.A.
Entity type:Organization
Organization Name:LEON ROTH M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FEAGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-455-2385
Mailing Address - Street 1:2500 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUIT Q,R
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4834
Mailing Address - Country:US
Mailing Address - Phone:954-455-2385
Mailing Address - Fax:954-454-5994
Practice Address - Street 1:2500 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUIT Q,R
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4834
Practice Address - Country:US
Practice Address - Phone:954-455-2385
Practice Address - Fax:954-454-5994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME18438261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD66034Medicare UPIN