Healthcare Provider Details

I. General information

NPI: 1033751169
Provider Name (Legal Business Name): ZAHAVA G ROTH PA-C, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/15/2023
Certification Date: 10/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W DEVON AVE
CHICAGO IL
60660-1302
US

IV. Provider business mailing address

2831 W FITCH AVE
CHICAGO IL
60645-2905
US

V. Phone/Fax

Practice location:
  • Phone: 773-751-7850
  • Fax:
Mailing address:
  • Phone: 773-595-6678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164009188
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.010009
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: