Healthcare Provider Details

I. General information

NPI: 1730186131
Provider Name (Legal Business Name): JOHN D ROBERTS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17430 SE 115TH TERRACE RD
SUMMERFIELD FL
34491-7825
US

IV. Provider business mailing address

17430 SE 115TH TERRACE RD
SUMMERFIELD FL
34491-7825
US

V. Phone/Fax

Practice location:
  • Phone: 270-319-1115
  • Fax:
Mailing address:
  • Phone: 270-319-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1048DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: