Provider Demographics
NPI:1104053982
Name:ROTH, ERLO (MD)
Entity type:Individual
Prefix:DR
First Name:ERLO
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E OGDEN AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3544
Mailing Address - Country:US
Mailing Address - Phone:630-986-9622
Mailing Address - Fax:630-986-0720
Practice Address - Street 1:120 E OGDEN AVE STE 14
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3544
Practice Address - Country:US
Practice Address - Phone:630-986-9622
Practice Address - Fax:630-986-0720
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050827207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL25583Medicare UPIN