MEDICARE: JACOB MICHAEL ROBISON 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	8015719-9934	UT
2	152W00000X	Optometrist	8015719-8908	UT

General Provider Information

NPI Number	:	1780970582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MICHAEL ROBISON O.D.

Provider Business Mailing Address
First Line	:	43 E 450 N
Second Line	:
City	:	EPHRAIM
State	:	UT
Zip	:	84627-4027
Country	:	US
Telephone Number	:	435-283-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	43 E 450 N
Second Line	:
City	:	EPHRAIM
State	:	UT
Zip	:	84627-4027
Country	:	US
Telephone Number	:	435-283-5555
Fax Number	:

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

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	06/21/2011

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