Healthcare Provider Details

I. General information

NPI: 1336121540
Provider Name (Legal Business Name): LEROY SIMONS ROBERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 N MAIN ST
WAYNESVILLE NC
28786-3886
US

IV. Provider business mailing address

29 N MAIN ST
WAYNESVILLE NC
28786-3886
US

V. Phone/Fax

Practice location:
  • Phone: 828-456-8361
  • Fax: 828-452-4527
Mailing address:
  • Phone: 828-456-8361
  • Fax: 828-452-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0928
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: