Provider Demographics
NPI:1255335808
Name:ROENFELDT, RICHARD L (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:ROENFELDT
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 1:2020 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2623
Mailing Address - Country:US
Mailing Address - Phone:620-225-0225
Mailing Address - Fax:620-225-8022
Practice Address - Street 1:2020 1ST AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2623
Practice Address - Country:US
Practice Address - Phone:620-225-0225
Practice Address - Fax:620-225-8022
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1188-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0708190001Medicare NSC