Provider Demographics
NPI:1073822169
Name:ROTELLA, MEGAN RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:RENEE
Last Name:ROTELLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:RUTHFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:213 PHILIP DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702
Mailing Address - Country:US
Mailing Address - Phone:503-840-4812
Mailing Address - Fax:
Practice Address - Street 1:2200 N MAPLE AVE
Practice Address - Street 2:ATTN: JCPENNEY OPTICAL
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7854
Practice Address - Country:US
Practice Address - Phone:605-341-7832
Practice Address - Fax:605-399-9319
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD696152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist