Provider Demographics
NPI:1427052323
Name:ROTTACH, BERNIE V (OD)
Entity type:Individual
Prefix:DR
First Name:BERNIE
Middle Name:V
Last Name:ROTTACH
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 1:2204 COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1547
Mailing Address - Country:US
Mailing Address - Phone:952-472-3937
Mailing Address - Fax:952-472-7487
Practice Address - Street 1:2204 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:MOUND
Practice Address - State:MN
Practice Address - Zip Code:55364-1547
Practice Address - Country:US
Practice Address - Phone:952-472-3937
Practice Address - Fax:952-472-7487
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN214140663001OtherPREFERRED ONE
MN2201983OtherMEDICA EXAM
MN074944300Medicaid
MN144L5ROOtherBLUE CROSS & BLUE SHIELD OF MN
MN2100307OtherMEDICA EYEWEAR
MN200111404OtherHEALTHPARTNERS
MN074944300Medicaid
MN200111404OtherHEALTHPARTNERS