Healthcare Provider Details

I. General information

NPI: 1508929134
Provider Name (Legal Business Name): DR GEORGE T ROBERTS OPTOMETRIST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 MAIN ST
SIDNEY NY
13838-1138
US

IV. Provider business mailing address

75 MAIN ST
SIDNEY NY
13838-1138
US

V. Phone/Fax

Practice location:
  • Phone: 607-563-7551
  • Fax: 607-563-2442
Mailing address:
  • Phone: 607-563-7551
  • Fax: 607-563-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV003200
License Number StateNY

VIII. Authorized Official

Name: MRS. KATHI J ROBERTS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 607-563-7551