Provider Demographics
NPI:1447314703
Name:TRUDELL, ROGER J (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
Last Name:TRUDELL
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 1:2565 TAMARACK AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0990
Mailing Address - Country:US
Mailing Address - Phone:303-443-4093
Mailing Address - Fax:
Practice Address - Street 1:412 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5535
Practice Address - Country:US
Practice Address - Phone:303-651-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2018-05-09
Deactivation Date:2018-04-30
Deactivation Code:
Reactivation Date:2018-05-09
Provider Licenses
StateLicense IDTaxonomies
CO1188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COT88837Medicare UPIN
CO380018Medicare ID - Type Unspecified
CO4482420001Medicare NSC