1477556421 NPI number — DR. STEVEN S. ROTH O.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	ROTH
Provider First Name	:	STEVEN
Provider Middle Name	:	S.
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	O.D.
Provider Gender Code	:	M

Provider Other Organization Name	:
Provider Other Organization Name Type Code	:
Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
Provider Other Name Prefix Text	:
Provider Other Name Suffix Text	:
Provider Other Credential Text	:
Provider Other Last Name Type Code	:

NPI Number	:	1477556421
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	1107 MANTUA PIKE
Provider Second Line Business Mailing Address	:	STE 722
Provider Business Mailing Address City Name	:	MANTUA
Provider Business Mailing Address State Name	:	NJ
Provider Business Mailing Address Postal Code	:	080511606
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	8564649000
Provider Business Mailing Address Fax Number	:	8564641577

Provider First Line Business Practice Location Address	:	1107 MANTUA PIKE
Provider Second Line Business Practice Location Address	:	STE 722
Provider Business Practice Location Address City Name	:	MANTUA
Provider Business Practice Location Address State Name	:	NJ
Provider Business Practice Location Address Postal Code	:	080511606
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	8564649000
Provider Business Practice Location Address Fax Number	:	8564641577
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:
Authorized Official First Name	:
Authorized Official Middle Name	:
Authorized Official Title or Position	:
Authorized Official Telephone Number	:

• Taxonomy code: 152W00000X , with the licence number:  27TO00030000 , registered in the state of NJ .
• Taxonomy code: 152W00000X , with the licence number: 27OA00378500 , registered in the state of NJ .

• Identifier: 2254417 , issued by the state of ( NJ ) . This identifiers is of the category "".
• Identifier: 0024503 . This identifiers is of the category "".
• Identifier: T77698 . This identifiers is of the category "".