Provider Demographics
NPI:1568675759
Name:ROTH, GERTRUDE ELSIE (OD)
Entity Type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:ELSIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 A LAWNDALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7102
Mailing Address - Country:US
Mailing Address - Phone:336-275-1254
Mailing Address - Fax:
Practice Address - Street 1:2154 A LAWNDALE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7102
Practice Address - Country:US
Practice Address - Phone:336-275-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1138152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246491AMedicare ID - Type Unspecified