Provider Demographics
NPI:1447396361
Name:ROTH, JOHN B JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:ROTH
Suffix:JR
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 1:107 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2128
Mailing Address - Country:US
Mailing Address - Phone:815-942-0683
Mailing Address - Fax:
Practice Address - Street 1:107 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-2128
Practice Address - Country:US
Practice Address - Phone:815-942-0683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044899207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044899Medicaid
ILC40424Medicare UPIN
IL211030Medicare ID - Type Unspecified