1679576474 NPI number — DR. REED T ROTH O.D.

Table of content: DR. REED T ROTH O.D. (NPI 1679576474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679576474 NPI number — DR. REED T ROTH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
REED
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1679576474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28370 KENSINGTON LN
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PERRYSBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43551-4163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-874-3125
Provider Business Mailing Address Fax Number:
419-874-8606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28370 KENSINGTON LN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-874-3125
Provider Business Practice Location Address Fax Number:
419-874-8606
Provider Enumeration Date:
05/24/2005

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: 152W00000X , with the licence number:  4965T1835 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03418 . This is a "PARAMOUNT HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000301272 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2151068 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 360954 . This is a "NATIONAL VISION ADMINISTR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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