MEDICARE: DR. MARY ELLEN 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
1	152WC0802X	Corneal and Contact Management Optometrist	3777	OH
2	152W00000X	Optometrist	3777	OH

General Provider Information

NPI Number	:	1912065160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ELLEN ROTH O.D.

Provider Business Mailing Address
First Line	:	PO BOX 880
Second Line	:
City	:	HUDSON
State	:	OH
Zip	:	44236-5880
Country	:	US
Telephone Number	:	330-697-4748
Fax Number	:	866-425-2239

Provider Business Practice Location Address
First Line	:	4157 BELDEN VILLAGE MALL
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2501
Country	:	US
Telephone Number	:	330-494-4140
Fax Number	:	866-425-2239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	01/24/2020

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