Provider Demographics
NPI:1174603997
Name:ROSTEN, JOHN GILLILAND (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GILLILAND
Last Name:ROSTEN
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 1:125 N LINCOLN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-3258
Mailing Address - Country:US
Mailing Address - Phone:707-678-3055
Mailing Address - Fax:707-678-9265
Practice Address - Street 1:125 N LINCOLN ST
Practice Address - Street 2:SUITE A
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-3258
Practice Address - Country:US
Practice Address - Phone:707-678-3055
Practice Address - Fax:707-678-9265
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6335T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13073OtherMEDICAL EYE SERVICES INC.
CASD0063350Medicaid
CAT10293Medicare UPIN
CASD0063350Medicaid
CASD0063351Medicare PIN