Provider Demographics
NPI:1588668081
Name:ROARK, DENNIS O (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:O
Last Name:ROARK
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 1:313 W HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1018
Mailing Address - Country:US
Mailing Address - Phone:937-399-1866
Mailing Address - Fax:937-399-2346
Practice Address - Street 1:1674 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2652
Practice Address - Country:US
Practice Address - Phone:937-399-4101
Practice Address - Fax:937-399-2346
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH200806361028OtherCARESOURCE
OH10943OtherCORDINATED VISION CARE
OH2220144OtherUNITED HEALTH CARE
OH000000340280OtherINDIVIDUAL
OH919227OtherINDIVIDUAL
OH0239665Medicaid
OH200806361028OtherCARESOURCE
OH0239665Medicaid