Provider Demographics
NPI:1902899651
Name:ROLEN, ROBERT D III (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:D
Last Name:ROLEN
Suffix:III
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 1:115 W HERMISTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-1711
Mailing Address - Country:US
Mailing Address - Phone:541-567-1837
Mailing Address - Fax:
Practice Address - Street 1:115 W HERMISTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1711
Practice Address - Country:US
Practice Address - Phone:541-567-1837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1795ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150839Medicaid
48207OtherBXBS
ORR0000PHFFBMedicare PIN
48207OtherBXBS
OR150839Medicaid