Provider Demographics
NPI:1972518348
Name:ROGER H PHELPS OD, INC.
Entity Type:Organization
Organization Name:ROGER H PHELPS OD, INC.
Other - Org Name:OJAIEYES OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-646-2020
Mailing Address - Street 1:216 E MATILIJA ST
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-2722
Mailing Address - Country:US
Mailing Address - Phone:805-646-2020
Mailing Address - Fax:805-646-5054
Practice Address - Street 1:216 E MATILIJA ST
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-2722
Practice Address - Country:US
Practice Address - Phone:805-646-2020
Practice Address - Fax:805-646-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5196TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD003090Medicaid
CAYYY34585YMedicaid
CAYYY34585YMedicaid
CAT09901Medicare UPIN
CAGSD003090Medicaid