Provider Demographics
NPI:1689669921
Name:HOPKINS, ROGER DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
Last Name:HOPKINS
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:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1692
Mailing Address - Country:US
Mailing Address - Phone:660-827-4120
Mailing Address - Fax:660-827-1525
Practice Address - Street 1:316 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-4245
Practice Address - Country:US
Practice Address - Phone:660-827-4120
Practice Address - Fax:660-827-1525
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2010-04-21
Deactivation Date:2009-09-24
Deactivation Code:
Reactivation Date:2010-04-21
Provider Licenses
StateLicense IDTaxonomies
MOT02192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05880017OtherBLUE CROSS BLUE SHIELD
MO310039714Medicaid
410017052OtherRR MEDICARE
410017052OtherRR MEDICARE
MO8291309Medicare ID - Type Unspecified
MO310039714Medicaid