Provider Demographics
NPI:1346380185
Name:ROTH, THOMAS BARKER (OPTOMETRIST OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BARKER
Last Name:ROTH
Suffix:
Gender:M
Credentials:OPTOMETRIST OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 PACKARD RD
Mailing Address - Street 2:STE #103
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6827
Mailing Address - Country:US
Mailing Address - Phone:734-973-1990
Mailing Address - Fax:
Practice Address - Street 1:2500 PACKARD RD
Practice Address - Street 2:STE #103
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6827
Practice Address - Country:US
Practice Address - Phone:734-973-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI90OH165310OtherBLUE CROSS BLUE SHIELD MI
MI5011007Medicaid
MIVLM0045OtherMCARE MI HEALTH INS CO
MI54OH10378OtherBLUE CROSS BLUE SHIELD MI
MIOH16573118901Medicare ID - Type Unspecified
MI90OH165310OtherBLUE CROSS BLUE SHIELD MI
MIVLM0045OtherMCARE MI HEALTH INS CO