Provider Demographics
NPI:1023014123
Name:ROTH, JERRY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:501 STREET RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3746
Mailing Address - Country:US
Mailing Address - Phone:215-357-5780
Mailing Address - Fax:
Practice Address - Street 1:501 STREET RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3796
Practice Address - Country:US
Practice Address - Phone:215-357-5780
Practice Address - Fax:215-364-8983
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030012E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA010903Medicare PIN