Healthcare Provider Details

I. General information

NPI: 1881633352
Provider Name (Legal Business Name): C. JACK ROFFIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1933 28TH ST STE. 206
BOULDER CO
80301-1100
US

IV. Provider business mailing address

6165 SIMMONS DR
BOULDER CO
80303-3007
US

V. Phone/Fax

Practice location:
  • Phone: 303-447-8470
  • Fax: 303-443-9555
Mailing address:
  • Phone: 303-499-5823
  • Fax: 303-499-5823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1277
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: