Provider Demographics
NPI:1124026687
Name:ROTH, S MOSHE (OD)
Entity Type:Individual
Prefix:
First Name:S MOSHE
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 US HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2690
Mailing Address - Country:US
Mailing Address - Phone:732-679-2020
Mailing Address - Fax:732-679-6980
Practice Address - Street 1:3111 US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-2690
Practice Address - Country:US
Practice Address - Phone:732-679-2020
Practice Address - Fax:732-679-2020
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA00463500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5021103Medicaid
NJ703284Medicare PIN
NJ5021103Medicaid
NJ0616520001Medicare NSC