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General NPI Number Information
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NPI Number | 1942577879
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Entity Type | Organization
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Legal Business Name | DORTHEANNE J. ROBERTS, OD PA
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Dates
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Enumeration Date | 11/21/2011
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Last Update Date | 11/21/2011
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Provider Practice Location Address
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Address Line | 401 BAY ST
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City | GREEN COVE SPRINGS
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State | FL
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Zip | 32043-4109
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Country | US
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Telephone | 904-529-9062
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Fax |
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Provider Business Mailing Address
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Address Line | 1486 WATER PIPIT LN
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-7238
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Country | US
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Telephone | 904-252-5426
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DORTHEANNE JOY ROBERTS
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Credential | OD
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Telephone | 904-252-5426
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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 | OPC4200
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License Number State | FL
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