Healthcare Provider Details

I. General information

NPI: 1366449977
Provider Name (Legal Business Name): RICHARD E ROTH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 RUTTER AVE
KINGSTON PA
18704-4801
US

IV. Provider business mailing address

703 RUTTER AVE
KINGSTON PA
18704-4801
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-7405
  • Fax: 570-288-7406
Mailing address:
  • Phone: 570-288-7405
  • Fax: 570-288-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberOS011086
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: