Provider Demographics
NPI:1225039571
Name:ROTH, JOHN T (AUD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:ROTH
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2225
Mailing Address - Country:US
Mailing Address - Phone:817-332-8817
Mailing Address - Fax:817-332-8827
Practice Address - Street 1:904 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2225
Practice Address - Country:US
Practice Address - Phone:817-332-8817
Practice Address - Fax:817-332-8827
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50455231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX514030OtherBCBS DIAG
TX015430-0111OtherPACIFICARE
TX0616049OtherAETNA
TX2313884OtherUNITED HEALTHCARE
TX4189557OtherCHESAPEAKE LIFE
TX01726OtherNECP, HEAR USA
TX519929OtherBCBS DME
TX015311-0202OtherSECUREHORIZONS
TX0616049OtherAETNA
TX514030Medicare PIN