1588668081 NPI number — DR. DENNIS O ROARK OD

Table of content: DR. DENNIS O ROARK OD (NPI 1588668081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588668081 NPI number — DR. DENNIS O ROARK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROARK
Provider First Name:
DENNIS
Provider Middle Name:
O
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588668081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
313 W HOME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45504-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-399-1866
Provider Business Mailing Address Fax Number:
937-399-2346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1674 N LIMESTONE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45503-2652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-399-4101
Provider Business Practice Location Address Fax Number:
937-399-2346
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2961 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200806361028 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 10943 . This is a "CORDINATED VISION CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2220144 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000340280 . This is a "INDIVIDUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 919227 . This is a "INDIVIDUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0239665 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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