Healthcare Provider Details

I. General information

NPI: 1679576474
Provider Name (Legal Business Name): REED T ROTH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28370 KENSINGTON LN SUITE A
PERRYSBURG OH
43551-4163
US

IV. Provider business mailing address

28370 KENSINGTON LN SUITE A
PERRYSBURG OH
43551-4163
US

V. Phone/Fax

Practice location:
  • Phone: 419-874-3125
  • Fax: 419-874-8606
Mailing address:
  • Phone: 419-874-3125
  • Fax: 419-874-8606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4965T1835
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: