Provider Demographics
NPI:1316940281
Name:MUNK, ROGER (OD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MUNK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:MUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:90 MARKET ST
Mailing Address - Street 2:STE 20
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2396
Mailing Address - Country:US
Mailing Address - Phone:541-451-1144
Mailing Address - Fax:541-451-1785
Practice Address - Street 1:90 MARKET ST
Practice Address - Street 2:STE 20
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2396
Practice Address - Country:US
Practice Address - Phone:541-451-1144
Practice Address - Fax:541-451-1785
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3080ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128772Medicaid
ORU50646Medicare UPIN
OR1211240001Medicare NSC
ORR00WFBYHAMedicare PIN