Provider Demographics
NPI:1477556421
Name:ROTH, STEVEN S (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:S
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 1:1107 MANTUA PIKE
Mailing Address - Street 2:STE 722
Mailing Address - City:MANTUA
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-1606
Mailing Address - Country:US
Mailing Address - Phone:856-464-9000
Mailing Address - Fax:856-464-1577
Practice Address - Street 1:1107 MANTUA PIKE
Practice Address - Street 2:STE 722
Practice Address - City:MANTUA
Practice Address - State:NJ
Practice Address - Zip Code:08051-1606
Practice Address - Country:US
Practice Address - Phone:856-464-9000
Practice Address - Fax:856-464-1577
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00378500152W00000X
NJ27TO00030000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2254417Medicaid
T77698Medicare UPIN
NJ2254417Medicaid