Healthcare Provider Details

I. General information

NPI: 1477556421
Provider Name (Legal Business Name): STEVEN S. ROTH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 MANTUA PIKE STE 722
MANTUA NJ
08051-1606
US

IV. Provider business mailing address

1107 MANTUA PIKE STE 722
MANTUA NJ
08051-1606
US

V. Phone/Fax

Practice location:
  • Phone: 856-464-9000
  • Fax: 856-464-1577
Mailing address:
  • Phone: 856-464-9000
  • Fax: 856-464-1577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00378500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27TO00030000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: