Provider Demographics
NPI:1083659015
Name:ROARK, STEPHEN RAY (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RAY
Last Name:ROARK
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 1:11745 FORT WORTH RD
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-6721
Mailing Address - Country:US
Mailing Address - Phone:719-597-4423
Mailing Address - Fax:719-596-6440
Practice Address - Street 1:3510 GALLEY RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4353
Practice Address - Country:US
Practice Address - Phone:719-597-4423
Practice Address - Fax:719-596-6440
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08014904Medicaid
CO457338Medicare ID - Type UnspecifiedPROVIDER NUMBER
COU29820Medicare UPIN