Provider Demographics
NPI:1013071075
Name:ROTH, JAMES GERARD (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GERARD
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 1:6857 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4151
Mailing Address - Country:US
Mailing Address - Phone:773-767-5000
Mailing Address - Fax:773-767-5176
Practice Address - Street 1:6857 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4151
Practice Address - Country:US
Practice Address - Phone:773-767-5000
Practice Address - Fax:773-767-5176
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08127171OtherBCBS OF IL
IL046008029Medicaid
IL046008029Medicaid
IL0595260001Medicare NSC
ILT36573Medicare UPIN