Basic Information
| Provider Information | |||||||||
| NPI: | 1811951999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTHER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 N COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734013920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802242900 | ||||||||
| FaxNumber: | 5802232397 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734013920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802242900 | ||||||||
| FaxNumber: | 5802232397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 17679 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110222036 | 01 | MEDICARE RAILROAD | OTHER | OKAAA0292 | 01 | OK | MEDICARE PTAN | OTHER | 100101430A | 05 | OK | MEDICAID |