Provider Demographics
NPI:1215916887
Name:ROTH, LAWRENCE JAY (OD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JAY
Last Name:ROTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 NORTHEAST AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1443
Mailing Address - Country:US
Mailing Address - Phone:330-633-9190
Mailing Address - Fax:330-633-6899
Practice Address - Street 1:384 NORTHEAST AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1443
Practice Address - Country:US
Practice Address - Phone:330-633-9190
Practice Address - Fax:330-633-6899
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T48448Medicare UPIN
RO0558622Medicare PIN