Provider Demographics
NPI:1437196631
Name:ROTH, JEFFREY M (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 ERIE BLVD W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2229
Mailing Address - Country:US
Mailing Address - Phone:315-475-2778
Mailing Address - Fax:315-471-3522
Practice Address - Street 1:725 ERIE BLVD W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2229
Practice Address - Country:US
Practice Address - Phone:315-475-2778
Practice Address - Fax:315-471-3522
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002684152W00000X
NY006532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB4958Medicare PIN