MEDICARE: DR. JILL LYNN ROBERTSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	105610199934	UT
2	152W00000X	Optometrist	2555	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	49941	OTHER	AR	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407966765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JILL LYNN ROBERTSON O.D.

Provider Business Mailing Address
First Line	:	2700 W HOMESTEAD ROAD, SUITE 30
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098
Country	:	US
Telephone Number	:	435-615-0435
Fax Number	:	435-604-0261

Provider Business Practice Location Address
First Line	:	2700 HOMESTEAD RD STE 30
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-4874
Country	:	US
Telephone Number	:	435-615-0435
Fax Number	:	435-604-0261

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	02/21/2018

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