Provider Demographics
NPI:1043381239
Name:ROTH, HOWARD I (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:I
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-933-1671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360791632085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079163Medicaid
IL4615054OtherBCBS ID
IL4615054OtherBCBS ID