Provider Demographics
NPI:1790787521
Name:ROTH, ANDREW A (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:A
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E 22ND ST STE A
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6102
Mailing Address - Country:US
Mailing Address - Phone:630-932-2055
Mailing Address - Fax:630-932-2059
Practice Address - Street 1:500 E 22ND ST STE A
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6102
Practice Address - Country:US
Practice Address - Phone:630-932-2055
Practice Address - Fax:630-932-2059
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0449143207V00000X
IL36079283207V00000X
VA0101273504207V00000X
UT13111717-1205207V00000X
KYC1158207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL931181Medicare ID - Type Unspecified
ILE57889Medicare UPIN