Provider Demographics
NPI:1588665384
Name:KLASSEN, ROGER A (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:KLASSEN
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 1:8504 S 100TH ST
Mailing Address - Street 2:
Mailing Address - City:LAVISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3072
Mailing Address - Country:US
Mailing Address - Phone:402-597-8990
Mailing Address - Fax:402-597-8992
Practice Address - Street 1:7904 S 83RD ST
Practice Address - Street 2:
Practice Address - City:LAVISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-2774
Practice Address - Country:US
Practice Address - Phone:402-597-8990
Practice Address - Fax:402-597-8992
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NE1055152W00000X
KS14293152W00000X
IA2153152W00000X
IN18002700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025067700Medicaid
NE10025067700Medicaid
271683Medicare ID - Type Unspecified