Provider Demographics
NPI:1306837307
Name:FITCH, ROGER W (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:FITCH
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 1:4727 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5925
Mailing Address - Country:US
Mailing Address - Phone:309-685-2020
Mailing Address - Fax:309-693-2536
Practice Address - Street 1:4727 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5925
Practice Address - Country:US
Practice Address - Phone:309-685-2020
Practice Address - Fax:309-693-2536
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT39770Medicare UPIN
IL212538Medicare PIN