Provider Demographics
NPI:1275660136
Name:ROTH, MATTHEW J (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3187 WESTERN ROW RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-8045
Mailing Address - Country:US
Mailing Address - Phone:513-770-3434
Mailing Address - Fax:513-229-5432
Practice Address - Street 1:3187 WESTERN ROW RD
Practice Address - Street 2:SUITE 114
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-8045
Practice Address - Country:US
Practice Address - Phone:513-770-3434
Practice Address - Fax:513-229-5432
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000313242OtherANTHEM
OH2378252Medicaid
OH2378252Medicaid
OH000000313242OtherANTHEM