Provider Demographics
NPI:1689776569
Name:RICHMOND E ROESKE A PROFESSIONAL CORP
Entity type:Organization
Organization Name:RICHMOND E ROESKE A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:RICHMOND
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROESKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-296-2244
Mailing Address - Street 1:41877 ENTERPRISE CIR N
Mailing Address - Street 2:STE 110
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5656
Mailing Address - Country:US
Mailing Address - Phone:951-296-2244
Mailing Address - Fax:951-296-3602
Practice Address - Street 1:41877 ENTERPRISE CIR N
Practice Address - Street 2:STE 110
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5656
Practice Address - Country:US
Practice Address - Phone:951-296-2244
Practice Address - Fax:951-296-3602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64048207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A640480Medicaid
CADD5158OtherRAILROAD MEDICARE
CAZZZ30322ZMedicare ID - Type Unspecified
CA00A640480Medicaid