1255517660 NPI number — DR. JONATHAN ROTH MD

Table of content: DR. JONATHAN ROTH MD (NPI 1255517660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255517660 NPI number — DR. JONATHAN ROTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
JONATHAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1255517660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 E 15TH ST
Provider Second Line Business Mailing Address:
150A
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013-6697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-348-6500
Provider Business Mailing Address Fax Number:
405-348-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 E 15TH ST
Provider Second Line Business Practice Location Address:
150A
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73013-6697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-348-6500
Provider Business Practice Location Address Fax Number:
405-348-6501
Provider Enumeration Date:
01/16/2008

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  26618 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 236223 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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