Provider Demographics
NPI:1710530241
Name:MOECKEL, ROMAN SCOT (OD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:SCOT
Last Name:MOECKEL
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 1:25350 W WARREN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2102
Mailing Address - Country:US
Mailing Address - Phone:313-563-2020
Mailing Address - Fax:313-274-1605
Practice Address - Street 1:25350 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2102
Practice Address - Country:US
Practice Address - Phone:313-563-2020
Practice Address - Fax:313-274-1605
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005410152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist