Provider Demographics
NPI:1356518138
Name:RICHARD E ROTH DO LLC
Entity type:Organization
Organization Name:RICHARD E ROTH DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-531-7702
Mailing Address - Street 1:608 NORTH BETHLEHEM PIKE
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002
Mailing Address - Country:US
Mailing Address - Phone:215-531-7702
Mailing Address - Fax:
Practice Address - Street 1:608 NORTH BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002
Practice Address - Country:US
Practice Address - Phone:215-531-7702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011086207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001968181Medicaid
049516Medicare UPIN