Healthcare Provider Details

I. General information

NPI: 1912065160
Provider Name (Legal Business Name): MARY ELLEN ROTH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4157 BELDEN VILLAGE MALL
CANTON OH
44718-2501
US

IV. Provider business mailing address

PO BOX 880
HUDSON OH
44236-5880
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-4140
  • Fax: 866-425-2239
Mailing address:
  • Phone: 330-697-4748
  • Fax: 866-425-2239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3777
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3777
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: