Provider Demographics
NPI:1770542516
Name:ROLLENHAGEN, SUSAN RAE (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:RAE
Last Name:ROLLENHAGEN
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 1:1107 SW GAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-1892
Mailing Address - Country:US
Mailing Address - Phone:785-271-8989
Mailing Address - Fax:785-228-0370
Practice Address - Street 1:1107 SW GAGE BLVD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-1892
Practice Address - Country:US
Practice Address - Phone:785-271-8989
Practice Address - Fax:785-228-0370
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS651090OtherBCBS
KSU76609Medicare UPIN
KS651090OtherBCBS
KS651090Medicare PIN