Provider Demographics
NPI:1417945320
Name:ROTH, JEFFREY IRA (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:IRA
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4385 JOHNS CREEK PKWY
Mailing Address - Street 2:STE 250
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6048
Mailing Address - Country:US
Mailing Address - Phone:770-623-1608
Mailing Address - Fax:678-992-2540
Practice Address - Street 1:4385 JOHNS CREEK PKWY
Practice Address - Street 2:STE 250
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6048
Practice Address - Country:US
Practice Address - Phone:770-623-1608
Practice Address - Fax:678-992-2540
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041654207Y00000X, 207YP0228X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000714381MMedicaid
GA000714381JMedicaid
GA000714381JMedicaid
GA000714381MMedicaid