Provider Demographics
NPI:1578595294
Name:RENGEL, ROGER LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEE
Last Name:RENGEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:700 VILLAGE CENTER DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3019
Mailing Address - Country:US
Mailing Address - Phone:651-482-1959
Mailing Address - Fax:651-482-1850
Practice Address - Street 1:700 VILLAGE CENTER DR
Practice Address - Street 2:SUITE 180
Practice Address - City:NORTH OAKS
Practice Address - State:MN
Practice Address - Zip Code:55127-3019
Practice Address - Country:US
Practice Address - Phone:651-482-1959
Practice Address - Fax:651-482-1850
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2009-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN157859294OtherNPI NUMBER
MN21326OtherHEALTHPARTNERS
MN965040671001OtherPREFERRED ONE
MNSC1009OtherSELECT CARE
MNOB800REOtherBLUE CROSS/ BLUE SHIELD
MN65138OtherMEDICARE TAX ID
MN580000012OtherMEDICARE PTAN
MN22-02741OtherMEDICA
MN754723400Medicaid
MN22-02741OtherMEDICA
MNOB800REOtherBLUE CROSS/ BLUE SHIELD