Provider Demographics
NPI:1972650943
Name:RUPP-MAIOLATESI, ROSEANN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROSEANN
Middle Name:MARIE
Last Name:RUPP-MAIOLATESI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-2027
Mailing Address - Country:US
Mailing Address - Phone:570-281-3332
Mailing Address - Fax:
Practice Address - Street 1:117 LACKAWANNA AVE
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-1449
Practice Address - Country:US
Practice Address - Phone:570-383-9601
Practice Address - Fax:570-383-9613
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE-007219-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA22504OtherGEISINGER
PA075223OtherFIRST PRIORITY HEALTH
PA396606OtherNVA
PA736553OtherUS HEALTH CARE
PA0014136220003Medicaid
PA396606OtherNVA
PAU18729Medicare UPIN