Provider Demographics
NPI:1780662577
Name:ROERS OTT, CHERYL MARIE (OD)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:MARIE
Last Name:ROERS OTT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CHERYL
Other - Middle Name:MARIE
Other - Last Name:ROERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:521 RIVER TER
Mailing Address - Street 2:
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042-1371
Mailing Address - Country:US
Mailing Address - Phone:920-918-5769
Mailing Address - Fax:
Practice Address - Street 1:1405 MILWAUKEE DR
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1430
Practice Address - Country:US
Practice Address - Phone:920-898-5531
Practice Address - Fax:920-898-1581
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2515152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38587700Medicaid
0001 47895Medicare ID - Type Unspecified
U37580Medicare UPIN