Provider Demographics
NPI:1679631808
Name:DRAKE, ROSE MARIE (OD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:MARIE
Other - Last Name:WILKEY, HOLTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1400 S LIMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5118
Mailing Address - Country:US
Mailing Address - Phone:660-827-3140
Mailing Address - Fax:
Practice Address - Street 1:1400 S LIMIT AVE
Practice Address - Street 2:SPACE 75 STATE FAIR SHOPPING CENTER
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5116
Practice Address - Country:US
Practice Address - Phone:660-827-3140
Practice Address - Fax:660-827-5204
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1978001Medicare PIN
MO172354Medicare UPIN