Provider Demographics
NPI:1811981624
Name:ROLAND, NATHANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:ROLAND
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 1:1955 NW NORTHRUP ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1614
Mailing Address - Country:US
Mailing Address - Phone:503-227-2020
Mailing Address - Fax:503-222-0614
Practice Address - Street 1:1955 NW NORTHRUP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1614
Practice Address - Country:US
Practice Address - Phone:503-227-2020
Practice Address - Fax:503-222-0614
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4046ATI152W00000X
NM557152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4046ATIOtherOPTOMETRIC LICENSE
NMP00796638OtherMEDICARE RAILROAD CARRIER
NM18438857Medicaid
NM343536200Medicare PIN
NMV03496Medicare UPIN
NMNM302985OtherMEDICARE INDIVIDUAL PTAN