Provider Demographics
NPI:1073595906
Name:FIELDS, RODERICK D (OD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:D
Last Name:FIELDS
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 1:431 BERTUCCI BLVD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531
Mailing Address - Country:US
Mailing Address - Phone:228-385-2020
Mailing Address - Fax:228-385-2020
Practice Address - Street 1:431 BERTUCCI BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531
Practice Address - Country:US
Practice Address - Phone:228-385-2020
Practice Address - Fax:228-385-2020
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087640Medicaid
MS410000170Medicare ID - Type Unspecified
MS00087640Medicaid