Provider Demographics
NPI:1720009913
Name:ROESKE, RICHMOND EMMERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHMOND
Middle Name:EMMERSON
Last Name:ROESKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4904
Mailing Address - Country:US
Mailing Address - Phone:909-982-8846
Mailing Address - Fax:909-949-3967
Practice Address - Street 1:555 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4904
Practice Address - Country:US
Practice Address - Phone:909-982-8846
Practice Address - Fax:909-949-3967
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64048207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A640480Medicaid
CA00A640480Medicaid
CA00A640480Medicare PIN
CA180039942Medicare PIN