Provider Demographics
NPI:1134514706
Name:ROTH, JASON (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 WILMINGTON W CHESTER PIKE STE 214
Mailing Address - Street 2:
Mailing Address - City:CHADDS FORD
Mailing Address - State:PA
Mailing Address - Zip Code:19317-9007
Mailing Address - Country:US
Mailing Address - Phone:844-365-7246
Mailing Address - Fax:610-361-7956
Practice Address - Street 1:405 SILVERSIDE RD STE 104
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-1768
Practice Address - Country:US
Practice Address - Phone:844-365-7246
Practice Address - Fax:844-516-0080
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0013778208100000X, 2081P2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE250588337Medicaid
MD452046700Medicaid