=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851556294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRIS ROBERTS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2008
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3250 VERNON BLVD
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-267-1260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 BERWICK RD
-----------------------------------------------------
City | HEWLETT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11557-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-267-1260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T-005377
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------