Healthcare Provider Details

I. General information

NPI: 1255365300
Provider Name (Legal Business Name): TIMOTHY WAYNE ROBERTSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SOLANO ST
CORNING CA
96021-3433
US

IV. Provider business mailing address

114 MISSION RANCH BLVD STE 50
CHICO CA
95926-5137
US

V. Phone/Fax

Practice location:
  • Phone: 530-824-2166
  • Fax: 530-824-5916
Mailing address:
  • Phone: 530-924-0749
  • Fax: 530-895-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP9551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: