Provider Demographics
NPI:1407944259
Name:WEIKUM, ROGER ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALLEN
Last Name:WEIKUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2100 ROSS AVE STE 260-LB4
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2739
Mailing Address - Country:US
Mailing Address - Phone:214-220-2425
Mailing Address - Fax:214-220-2488
Practice Address - Street 1:2100 ROSS AVE STE 260-LB-4
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-2717
Practice Address - Country:US
Practice Address - Phone:214-220-2425
Practice Address - Fax:214-220-2488
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002243TG152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT16531Medicare UPIN
TXTXB118986Medicare PIN