Provider Demographics
NPI:1154620383
Name:ROTH, MARSHALL D (LAC)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:D
Last Name:ROTH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 W 95TH ST
Mailing Address - Street 2:SUITE LL6
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2533
Mailing Address - Country:US
Mailing Address - Phone:708-422-7600
Mailing Address - Fax:
Practice Address - Street 1:4700 W 95TH ST
Practice Address - Street 2:SUITE LL6
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2533
Practice Address - Country:US
Practice Address - Phone:708-422-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198-000524171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist