Provider Demographics
NPI:1063489177
Name:ROETMAN, MICHAEL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:ROETMAN
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 1:502 FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:51246
Mailing Address - Country:US
Mailing Address - Phone:712-472-3464
Mailing Address - Fax:712-472-2788
Practice Address - Street 1:502 1ST AVE
Practice Address - Street 2:
Practice Address - City:ROCK RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:51246-1014
Practice Address - Country:US
Practice Address - Phone:712-472-3464
Practice Address - Fax:712-472-2788
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA1754152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0114165Medicaid
IA0114165Medicaid
I6226Medicare ID - Type Unspecified