Provider Demographics
NPI:1013022664
Name:ROBERTSON, LARRY E (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:E
Last Name:ROBERTSON
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 1:20279 DANNY CT
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-8618
Mailing Address - Country:US
Mailing Address - Phone:503-655-1611
Mailing Address - Fax:
Practice Address - Street 1:12100 SE STEVENS CT STE 106
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-8707
Practice Address - Country:US
Practice Address - Phone:503-653-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1362ATI152W00000X
WA1179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist