Provider Demographics
NPI:1386703296
Name:BRUCE J ROGERS
Entity type:Organization
Organization Name:BRUCE J ROGERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN OWNER
Authorized Official - Phone:315-265-2675
Mailing Address - Street 1:22 DEPOT ST.
Mailing Address - Street 2:MARKET SQURE MALL SUITE Z
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-265-2675
Mailing Address - Fax:315-265-3899
Practice Address - Street 1:22 DEPOT ST
Practice Address - Street 2:MARKET SQURE MALL SUITE Z
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1140
Practice Address - Country:US
Practice Address - Phone:315-265-2675
Practice Address - Fax:315-265-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0055651156FX1800X
NY332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1253040001Medicare NSC