Provider Demographics
NPI:1679576474
Name:ROTH, REED T (OD)
Entity Type:Individual
Prefix:DR
First Name:REED
Middle Name:T
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 1:28370 KENSINGTON LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-4163
Mailing Address - Country:US
Mailing Address - Phone:419-874-3125
Mailing Address - Fax:419-874-8606
Practice Address - Street 1:28370 KENSINGTON LN
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-4163
Practice Address - Country:US
Practice Address - Phone:419-874-3125
Practice Address - Fax:419-874-8606
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4965T1835152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03418OtherPARAMOUNT HEALTH CARE
OH000000301272OtherANTHEM BC/BS
OH2151068Medicaid
OH360954OtherNATIONAL VISION ADMINISTR
P00044474Medicare PIN
OH360954OtherNATIONAL VISION ADMINISTR
OHRO0869214Medicare PIN