Provider Demographics
NPI:1922036458
Name:ROTH, DAVID M (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-2509
Mailing Address - Country:US
Mailing Address - Phone:305-984-8476
Mailing Address - Fax:305-532-7684
Practice Address - Street 1:136 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33132-2509
Practice Address - Country:US
Practice Address - Phone:305-374-5127
Practice Address - Fax:305-374-2123
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2436152WC0802X
FL2436152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078818000Medicaid
FL078818000Medicaid
FL20283Medicare PIN