Provider Demographics
NPI:1003885138
Name:ROBERTS, ROGER D (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 E JOYCE BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6391
Mailing Address - Country:US
Mailing Address - Phone:479-582-9119
Mailing Address - Fax:
Practice Address - Street 1:745 E JOYCE BLVD STE 124
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6391
Practice Address - Country:US
Practice Address - Phone:795-829-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4019152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007739Medicaid
L91222Medicare PIN