Provider Demographics
NPI:1417639022
Name:ROCKWELL, ETHAN (OD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ROCKWELL
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 1:1201 TARA HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3090
Mailing Address - Country:US
Mailing Address - Phone:515-865-3575
Mailing Address - Fax:
Practice Address - Street 1:3610 W NORFOLK AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-7702
Practice Address - Country:US
Practice Address - Phone:402-371-8230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1625152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist