Provider Demographics
NPI:1043204183
Name:CRESS, ROBERT MENDENHALL
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MENDENHALL
Last Name:CRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4939
Mailing Address - Country:US
Mailing Address - Phone:803-534-2352
Mailing Address - Fax:803-543-2180
Practice Address - Street 1:1605 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4939
Practice Address - Country:US
Practice Address - Phone:803-534-2352
Practice Address - Fax:803-543-2180
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2009-07-16
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
SC00559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD05591Medicaid
SCP00700974Medicare PIN
SC9127Medicare PIN
SCD05591Medicaid
SC6161420002Medicare NSC