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General NPI Number Information
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NPI Number | 1851663512
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Entity Type | Organization
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Legal Business Name | OPTIC ART III, PLLC
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Dates
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Enumeration Date | 01/27/2012
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Last Update Date | 01/27/2012
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Provider Practice Location Address
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Address Line | 213 N MAIN ST
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City | MOSCOW
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State | ID
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Zip | 83843-2700
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Country | US
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Telephone | 208-882-2932
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Fax |
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Provider Business Mailing Address
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Address Line | 213 N MAIN ST
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City | MOSCOW
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State | ID
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Zip | 83843-2700
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Country | US
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Telephone | 208-882-2932
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIC PHYSICIAN
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Name | DR. RODGER DEAN ROBERTSON
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Credential | O.D.
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Telephone | 208-882-2932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-552
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License Number State | ID
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