Provider Demographics
NPI:1891887410
Name:ROGGENSACK, ROBERT J (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:ROGGENSACK
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 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-494-3041
Mailing Address - Fax:641-494-3059
Practice Address - Street 1:620 N 8TH ST
Practice Address - Street 2:
Practice Address - City:OSAGE
Practice Address - State:IA
Practice Address - Zip Code:50461-1456
Practice Address - Country:US
Practice Address - Phone:641-723-6100
Practice Address - Fax:641-723-6108
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01851152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0250357Medicaid
IA25035OtherWELLMARK
IA25035Medicare ID - Type Unspecified
IAT65207Medicare UPIN
IA0829160002Medicare NSC