Provider Demographics
NPI:1508874280
Name:RODERICK, MARISSA EMILY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:EMILY
Last Name:RODERICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:MARISSA
Other - Middle Name:EMILY
Other - Last Name:KRUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9911 E 21ST ST N
Mailing Address - Street 2:APT 1307
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3551
Mailing Address - Country:US
Mailing Address - Phone:316-636-9551
Mailing Address - Fax:
Practice Address - Street 1:4600 W KELLOGG DR
Practice Address - Street 2:SUITE 215
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2568
Practice Address - Country:US
Practice Address - Phone:316-943-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist