Provider Demographics
NPI:1033751169
Name:ROTH, ZAHAVA G (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:ZAHAVA
Middle Name:G
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 W FITCH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2905
Mailing Address - Country:US
Mailing Address - Phone:773-595-6678
Mailing Address - Fax:
Practice Address - Street 1:1300 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1302
Practice Address - Country:US
Practice Address - Phone:773-751-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164009188133V00000X
IL085.010009363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered