Provider Demographics
NPI:1902599418
Name:ROTH, MADISON (OD)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 WAGON WHEEL TRL
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1664 NEIL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2333
Practice Address - Country:US
Practice Address - Phone:614-292-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007138152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist