Provider Demographics
NPI:1881661031
Name:ROTH, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1513 UNION AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9404
Mailing Address - Country:US
Mailing Address - Phone:660-269-3191
Mailing Address - Fax:660-269-2943
Practice Address - Street 1:1513 UNION AVE STE 1600
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9404
Practice Address - Country:US
Practice Address - Phone:660-269-8752
Practice Address - Fax:660-269-8753
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2015-00054208600000X
IA34184208600000X
IL036105151208600000X
MO2015008450208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1881661031Medicaid
NCNC0186AMedicare PIN
ILH42596Medicare UPIN