Provider Demographics
NPI:1568657443
Name:ROTH VISION CARE, DOCTOR OF OPTOMETRY, PLLC
Entity Type:Organization
Organization Name:ROTH VISION CARE, DOCTOR OF OPTOMETRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-475-2778
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA1213Medicare PIN