Basic Information
| Provider Information | |||||||||
| NPI: | 1376549378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTTLER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630251205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6369382650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2946 HIGHWAY K | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633667861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362401516 | ||||||||
| FaxNumber: | 6362721323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | T02819 | MO | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 046008288 | IL | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 410047667 | 01 | MO | RAILROAD MEDICARE | OTHER | 314901703 | 05 | MO | MEDICAID |