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General NPI Number Information
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NPI Number | 1871891853
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Entity Type | Organization
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Legal Business Name | JONATHAN B ROTH LLC
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Dates
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Enumeration Date | 03/01/2011
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Last Update Date | 03/01/2011
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Provider Practice Location Address
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Address Line | 2000 E 15TH ST 150A
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City | EDMOND
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State | OK
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Zip | 73013-6697
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Country | US
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Telephone | 405-348-6500
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Fax | 405-348-6501
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Provider Business Mailing Address
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Address Line | 2000 E 15TH ST STE 150A
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City | EDMOND
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State | OK
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Zip | 73013-6679
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Country | US
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Telephone | 405-348-6500
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Fax | 405-348-6501
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Authorized Official
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Title or Position | MD
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Name | JONATHAN B ROTH
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Credential | MD
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Telephone | 405-348-6500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 26618
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License Number State | OK
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