Provider Demographics
NPI:1932397858
Name:ROGER TOTTEN OD PA
Entity Type:Organization
Organization Name:ROGER TOTTEN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:TOTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-368-7921
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-0097
Mailing Address - Country:US
Mailing Address - Phone:870-368-7921
Mailing Address - Fax:870-368-7789
Practice Address - Street 1:102 SPRING STREET
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556
Practice Address - Country:US
Practice Address - Phone:870-368-7921
Practice Address - Fax:870-368-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140563722Medicaid
ARDN0083OtherRR MEDICARE
AR=========OtherTRICARE
AR140563722Medicaid
AR0481510001Medicare NSC