Provider Demographics
NPI:1053683037
Name:CARL J ROTH OD PC
Entity Type:Organization
Organization Name:CARL J ROTH OD PC
Other - Org Name:BRIDGER EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:406-587-2020
Mailing Address - Street 1:113 E OAK ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-2972
Mailing Address - Country:US
Mailing Address - Phone:406-587-2020
Mailing Address - Fax:844-965-9460
Practice Address - Street 1:113 E OAK ST STE 2C
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2972
Practice Address - Country:US
Practice Address - Phone:406-587-2020
Practice Address - Fax:844-965-9460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
MT675332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty