Healthcare Provider Details

I. General information

NPI: 1972665883
Provider Name (Legal Business Name): DAVID A ROBERTS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 04/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 LAKELAND HILLS BLVD
LAKELAND FL
33805-4673
US

IV. Provider business mailing address

1950 OLD GALLOWS RD SUITE 520
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-2260
  • Fax: 863-595-0927
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-991-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC2385
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8843-T
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2385
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: