Healthcare Provider Details

I. General information

NPI: 1942499660
Provider Name (Legal Business Name): DAVID L ROBERTS O D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 N BROADWAY ST
POTEAU OK
74953-2501
US

IV. Provider business mailing address

PO BOX 829
POTEAU OK
74953-0829
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-3284
  • Fax: 918-647-3394
Mailing address:
  • Phone: 918-647-3284
  • Fax: 918-647-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number781
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number781
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID L ROBERTS
Title or Position: OWNER
Credential: O.D.
Phone: 918-647-3284