Healthcare Provider Details

I. General information

NPI: 1720009913
Provider Name (Legal Business Name): RICHMOND EMMERSON ROESKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N 13TH AVE
UPLAND CA
91786-4904
US

IV. Provider business mailing address

555 N 13TH AVE
UPLAND CA
91786-4904
US

V. Phone/Fax

Practice location:
  • Phone: 909-982-8846
  • Fax: 909-949-3967
Mailing address:
  • Phone: 909-982-8846
  • Fax: 909-949-3967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA64048
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: