Basic Information
| Provider Information | |||||||||
| NPI: | 1881661031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1513 UNION AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652709404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602693191 | ||||||||
| FaxNumber: | 6602692943 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 UNION AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652709404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602698752 | ||||||||
| FaxNumber: | 6602698753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2015-00054 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 34184 | IA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 036105151 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 2015008450 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1881661031 | 05 | NC | MEDICAID |