Provider Demographics
NPI:1306908314
Name:GROTH, MARITZA LASTRA (MD)
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:LASTRA
Last Name:GROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5540
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11802-5540
Mailing Address - Country:US
Mailing Address - Phone:631-473-0037
Mailing Address - Fax:631-473-0228
Practice Address - Street 1:70 N COUNTRY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2161
Practice Address - Country:US
Practice Address - Phone:631-473-0037
Practice Address - Fax:631-473-0228
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159478207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01211009Medicaid
NY71F191Medicare ID - Type Unspecified
NY01211009Medicaid