Basic Information
Provider Information | |||||||||
NPI: | 1346382868 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTH | ||||||||
FirstName: | BARRY | ||||||||
MiddleName: | HOWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 432 | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | NH | ||||||||
PostalCode: | 035840432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037882521 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 320 WASHINGTON ST | ||||||||
Address2: | SUITE 4 | ||||||||
City: | BROOKLINE | ||||||||
State: | MA | ||||||||
PostalCode: | 024456873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037882521 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2007 | ||||||||
LastUpdateDate: | 06/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 38670 | MA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1019885 | 05 | VT |   | MEDICAID | CO479301 | 01 | NH | MEDICARE PTAN | OTHER | C04793 | 01 | MA | BLUE CROSS BLUE SHIELD OF | OTHER | 0163724 | 05 | MA |   | MEDICAID | 715332 | 01 | MA | TUFTS | OTHER | 30003937 | 05 | NH |   | MEDICAID |