Provider Demographics
NPI:1326183633
Name:ROTH, KRISTINE WILHELMINA (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:WILHELMINA
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2825 LIVERNOIS RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1214
Mailing Address - Country:US
Mailing Address - Phone:313-205-6056
Mailing Address - Fax:248-680-2099
Practice Address - Street 1:2825 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1214
Practice Address - Country:US
Practice Address - Phone:313-205-6056
Practice Address - Fax:248-680-2099
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010818742084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry