Provider Demographics
NPI:1396752721
Name:ROTH, JEFFREY DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E WASHINGTON ST
Mailing Address - Street 2:SUITE 1811
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:312-444-1041
Mailing Address - Fax:312-444-1048
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:SUITE 1811
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-444-1041
Practice Address - Fax:312-444-1048
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031600526OtherBC/BS
IL0031600526OtherBC/BS
IL659830Medicare ID - Type Unspecified