Healthcare Provider Details

I. General information

NPI: 1881661031
Provider Name (Legal Business Name): JOHN W. ROTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 UNION AVE STE 1600
MOBERLY MO
65270-9404
US

IV. Provider business mailing address

1513 UNION AVE STE 1600
MOBERLY MO
65270-9404
US

V. Phone/Fax

Practice location:
  • Phone: 660-269-8752
  • Fax: 660-269-8753
Mailing address:
  • Phone: 660-269-3191
  • Fax: 660-269-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015-00054
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34184
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036105151
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015008450
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: