Provider Demographics
NPI:1679623938
Name:ROTH, ELLIOT R (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:R
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 1:1810 N JERUSALEM RD
Mailing Address - Street 2:
Mailing Address - City:N BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-1108
Mailing Address - Country:US
Mailing Address - Phone:516-214-6815
Mailing Address - Fax:
Practice Address - Street 1:1810 N JERUSALEM RD
Practice Address - Street 2:
Practice Address - City:N BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1108
Practice Address - Country:US
Practice Address - Phone:516-214-6815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005485152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU52438Medicare UPIN