Provider Demographics
NPI:1144210519
Name:RHOMBERG, MARY BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BETH
Last Name:RHOMBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:PATIENT CARE CENTER
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-516-5131
Mailing Address - Fax:314-516-5507
Practice Address - Street 1:7840 NATURAL BRIDGE RD
Practice Address - Street 2:PATIENT CARE CENTER
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4617
Practice Address - Country:US
Practice Address - Phone:314-516-5131
Practice Address - Fax:314-516-5507
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009203152W00000X
MOT03344152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1144210519Medicaid
MO067820028Medicare PIN
MO074730006Medicare PIN
MO1144210519Medicaid
IL351900004Medicare PIN
MO067820028Medicare PIN