Provider Demographics
NPI:1730284274
Name:BURCH, ROGER LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEE
Last Name:BURCH
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 39
Mailing Address - Street 2:
Mailing Address - City:CANEY
Mailing Address - State:KS
Mailing Address - Zip Code:67333-0039
Mailing Address - Country:US
Mailing Address - Phone:620-879-2415
Mailing Address - Fax:
Practice Address - Street 1:124 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:CANEY
Practice Address - State:KS
Practice Address - Zip Code:67333-1460
Practice Address - Country:US
Practice Address - Phone:620-879-2020
Practice Address - Fax:620-879-5381
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1031-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100091060AMedicaid
005306Medicare ID - Type Unspecified
KS100091060AMedicaid
KS0309440001Medicare NSC