MEDICARE: DR. RICHARD WALTER ROTH OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2025T	OR

General Provider Information

NPI Number	:	1588744403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD WALTER ROTH OD

Provider Business Mailing Address
First Line	:	4441 SE WOODSTOCK BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6271
Country	:	US
Telephone Number	:	503-775-4550
Fax Number	:	503-775-3208

Provider Business Practice Location Address
First Line	:	4441 SE WOODSTOCK BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6271
Country	:	US
Telephone Number	:	503-775-4550
Fax Number	:	503-775-3208

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	11/27/2007

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