Provider Demographics
NPI:1588744403
Name:ROTH, RICHARD WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WALTER
Last Name:ROTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4441 SE WOODSTOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6271
Mailing Address - Country:US
Mailing Address - Phone:503-775-4550
Mailing Address - Fax:503-775-3208
Practice Address - Street 1:4441 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6271
Practice Address - Country:US
Practice Address - Phone:503-775-4550
Practice Address - Fax:503-775-3208
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2025T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000PHGHRMedicare PIN