Provider Demographics
NPI:1801822242
Name:ROISMAN, TULLY STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:TULLY
Middle Name:STEPHEN
Last Name:ROISMAN
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 1:1151 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3705
Mailing Address - Country:US
Mailing Address - Phone:304-529-2800
Mailing Address - Fax:304-529-2802
Practice Address - Street 1:1151 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3705
Practice Address - Country:US
Practice Address - Phone:304-529-2800
Practice Address - Fax:304-529-2802
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12735207W00000X
KY23615207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0096811000Medicaid
KY64695562Medicaid
WV0499286Medicare ID - Type Unspecified
WV0096811000Medicaid
A72141Medicare UPIN