Provider Demographics
NPI:1811169634
Name:ROSELIUS, ROBERT THOMAS (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:ROSELIUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:ROSELIUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2600 DENALI ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2746
Mailing Address - Country:US
Mailing Address - Phone:907-274-7825
Mailing Address - Fax:
Practice Address - Street 1:2600 DENALI ST
Practice Address - Street 2:SUITE 603
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2746
Practice Address - Country:US
Practice Address - Phone:907-274-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK71152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP0070Medicaid
AKU58964Medicare UPIN
AKK0000PHFTJMedicare PIN