Basic Information
| Provider Information | |||||||||
| NPI: | 1962599944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 POWDER MILL LN | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190964035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106420801 | ||||||||
| FaxNumber: | 2155461943 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 WALNUT ST | ||||||||
| Address2: | AMERICAS BEST | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155461666 | ||||||||
| FaxNumber: | 2155461943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG000696 | PA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.