Provider Demographics
NPI:1245383918
Name:PABST, ROGER DALE (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:PABST
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 1:500 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56283-1168
Mailing Address - Country:US
Mailing Address - Phone:507-637-5715
Mailing Address - Fax:507-637-5715
Practice Address - Street 1:500 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:REDWOOD FALLS
Practice Address - State:MN
Practice Address - Zip Code:56283-1168
Practice Address - Country:US
Practice Address - Phone:507-637-5715
Practice Address - Fax:507-637-5715
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1616152W00000X
OR1289T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN47237PAOtherBLUECROSSBLUESHIELD
MN105T2PAOtherBLUECROSSBLUESHIELD
2738OtherHEALTH PARTNERS
MN0292480001Medicare NSC
MN47237PAOtherBLUECROSSBLUESHIELD