Provider Demographics
NPI:1669470175
Name:ROTH, ALAN JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:JOHN
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 1:229 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-1547
Mailing Address - Country:US
Mailing Address - Phone:814-834-1221
Mailing Address - Fax:814-834-3677
Practice Address - Street 1:229 ASH ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1547
Practice Address - Country:US
Practice Address - Phone:814-834-1221
Practice Address - Fax:814-834-3677
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE000620G152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0547309/01Medicaid
PA0547309/01Medicaid
PA112617Medicare PIN