Provider Demographics
NPI:1922202977
Name:DR. STEVEN S. ROTH, WEST DEPTFORD EYE CARE
Entity Type:Organization
Organization Name:DR. STEVEN S. ROTH, WEST DEPTFORD EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:856-464-9000
Mailing Address - Street 1:1107 MANTUA PIKE
Mailing Address - Street 2:SUITE 722
Mailing Address - City:MANTUA
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-1606
Mailing Address - Country:US
Mailing Address - Phone:856-464-9000
Mailing Address - Fax:856-464-1577
Practice Address - Street 1:1107 MANTUA PIKE
Practice Address - Street 2:SUITE 722
Practice Address - City:MANTUA
Practice Address - State:NJ
Practice Address - Zip Code:08051-1606
Practice Address - Country:US
Practice Address - Phone:856-464-9000
Practice Address - Fax:856-464-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00378500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2254417Medicaid
NJ24503Medicare ID - Type Unspecified
NJ2254417Medicaid