Provider Demographics
NPI:1710153382
Name:SIDNEY ROTH, O.D. INC.
Entity Type:Organization
Organization Name:SIDNEY ROTH, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-633-9190
Mailing Address - Street 1:384 NORTHEAST AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1443
Mailing Address - Country:US
Mailing Address - Phone:330-633-9190
Mailing Address - Fax:330-633-6899
Practice Address - Street 1:384 NORTHEAST AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1443
Practice Address - Country:US
Practice Address - Phone:330-633-9190
Practice Address - Fax:330-633-6899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0585862Medicaid
OHT48448Medicaid
OHT48448Medicaid
OHR00588622Medicare PIN
OH9932971Medicare PIN