Provider Demographics
NPI:1053574954
Name:ROTH, MARLENE MARGARET (MD)
Entity type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:MARGARET
Last Name:ROTH
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 1:31815 SOUTHFIELD RD STE 10
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5471
Mailing Address - Country:US
Mailing Address - Phone:248-644-2700
Mailing Address - Fax:248-644-4783
Practice Address - Street 1:31815 SOUTHFIELD RD
Practice Address - Street 2:SUITE 14
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-644-2700
Practice Address - Fax:248-644-4783
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067678208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics