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NPI Code Detail

MEDICARE: DR. JAMES GERARD ROTH O.D.

MEDICARE: DR. JAMES GERARD ROTH O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist046008029IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
108127171OTHERILBCBS OF IL
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1013071075
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JAMES GERARD ROTH O.D.
Provider Business Mailing Address
First Line : 6857 S PULASKI RD
Second Line :
City : CHICAGO
State : IL
Zip : 60629-4151
Country : US
Telephone Number : 773-767-5000
Fax Number : 773-767-5176
Provider Business Practice Location Address
First Line : 6857 S PULASKI RD
Second Line :
City : CHICAGO
State : IL
Zip : 60629-4151
Country : US
Telephone Number : 773-767-5000
Fax Number : 773-767-5176
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/21/2006
Last Update Date : 10/09/2008

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