Provider Demographics
NPI:1417050246
Name:ROEDER, VICTOR H III (OD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:H
Last Name:ROEDER
Suffix:III
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 1:113 WATSON ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-1326
Mailing Address - Country:US
Mailing Address - Phone:920-748-2676
Mailing Address - Fax:920-748-5105
Practice Address - Street 1:113 WATSON ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-1326
Practice Address - Country:US
Practice Address - Phone:920-748-2676
Practice Address - Fax:920-748-5105
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2466-035152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38591300Medicaid
WI38591300Medicaid
WIU20778Medicare UPIN