Provider Demographics
NPI:1487872198
Name:PHELPS, ROGER HAROLD (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:HAROLD
Last Name:PHELPS
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 1:216 E MATILIJA ST
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-2722
Mailing Address - Country:US
Mailing Address - Phone:805-646-2020
Mailing Address - Fax:805-646-5054
Practice Address - Street 1:216 E MATILIJA ST
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-2722
Practice Address - Country:US
Practice Address - Phone:805-646-2020
Practice Address - Fax:805-646-5054
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5196TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY34585YMedicaid
CAWOP5196BMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
CAYYY34585YMedicaid