Provider Demographics
NPI:1174596738
Name:ROTH, CARL J III (OD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:J
Last Name:ROTH
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2800 11TH AVE S STE 14
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5263
Mailing Address - Country:US
Mailing Address - Phone:406-455-2020
Mailing Address - Fax:406-771-6816
Practice Address - Street 1:2800 11TH AVE S STE 14
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5263
Practice Address - Country:US
Practice Address - Phone:406-455-2020
Practice Address - Fax:406-771-6816
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000027131OtherBLUE CROSS BLUE SHIELD
MT0000481219Medicaid
410042781OtherRAILROAD MEDICARE
MTMSF1137622OtherMONTANA STATE FUND
MT000027131OtherBLUE CROSS BLUE SHIELD
000025032Medicare ID - Type Unspecified
410042781OtherRAILROAD MEDICARE