Healthcare Provider Details

I. General information

NPI: 1063489177
Provider Name (Legal Business Name): MICHAEL LEE ROETMAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 1ST AVE
ROCK RAPIDS IA
51246-1014
US

IV. Provider business mailing address

502 FIRST AVE
ROCK RAPIDS IA
51246
US

V. Phone/Fax

Practice location:
  • Phone: 712-472-3464
  • Fax: 712-472-2788
Mailing address:
  • Phone: 712-472-3464
  • Fax: 712-472-2788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberIA1754
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: