Provider Demographics
NPI:1427055953
Name:ROTH, MONIQUE E (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:E
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 9120
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02027-9120
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:781-278-5667
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:781-278-5667
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA75907207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0300320OtherUNITED HEALTHCARE(HMO/PPO
075907OtherTUFTS
MA2733572OtherHEALTHSOURCE
0014523OtherNEIGHBORHOOD HEALTH PLAN
401095OtherHARVARD PILGRIM PPO
070013072OtherRAILROAD MEDICARE
2733572OtherCIGNA HEALTH CARE
27684OtherCHILDREN'S MED. SECURITY
3193B70OtherMASS.HEALTH(DIV.MEDSVCS)
401095OtherHARVARD PILGRIM
401095OtherHARVARD PILGRIM POS
J16188OtherBLUE SHIELD INDEMNITY
J16188OtherBS-BLUE CARE ELECT
075907OtherTUFTS BENEFIT ADMIN.
075907OtherTUFTS COMMONWEALTH PPO
075907OtherTUFTS TOTAL HEALTH PLAN
G17464OtherFIRST SENIORITY
J16188OtherHMO BLUE/BLUE CHOICE
0300320OtherUNITED HEALTHCARE(HMO/PPO
J16188OtherBS-BLUE CARE ELECT