Provider Demographics
NPI:1851436505
Name:ROOSE, RICHARD J (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:ROOSE
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 1:300 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-4218
Mailing Address - Country:US
Mailing Address - Phone:248-585-5212
Mailing Address - Fax:248-585-0355
Practice Address - Street 1:300 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4218
Practice Address - Country:US
Practice Address - Phone:248-585-5212
Practice Address - Fax:248-585-0355
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003893152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist