Provider Demographics
NPI:1033180336
Name:ROBERTS, JERRY D (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
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 1:507 E CLEVELAND AVE
Mailing Address - Street 2:PO BOX 351
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-1750
Mailing Address - Country:US
Mailing Address - Phone:417-235-5250
Mailing Address - Fax:417-235-5250
Practice Address - Street 1:507 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-1750
Practice Address - Country:US
Practice Address - Phone:417-235-5250
Practice Address - Fax:417-235-5250
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312562606Medicaid
MO0000009373Medicare PIN
T42625Medicare UPIN
MO003014044Medicare PIN