Provider Demographics
NPI:1831181973
Name:RALLO, ROD (OD)
Entity type:Individual
Prefix:DR
First Name:ROD
Middle Name:
Last Name:RALLO
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 1:4000 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1524
Mailing Address - Country:US
Mailing Address - Phone:502-459-2020
Mailing Address - Fax:502-456-5925
Practice Address - Street 1:4000 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1524
Practice Address - Country:US
Practice Address - Phone:502-459-2020
Practice Address - Fax:502-456-5925
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0936DT152W00000X
KY332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009363Medicaid
KY000000350896OtherANTHEM BCBS
KY0936DTOtherOD LICENSE NUMBER
KYP00202733OtherRR MEDICARE
KY000000350896OtherANTHEM BCBS
KY5419240010Medicare NSC
KY0936DTOtherOD LICENSE NUMBER