Provider Demographics
NPI:1053321984
Name:THEAKER, ROBERT M (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:THEAKER
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 1:365 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-3834
Mailing Address - Country:US
Mailing Address - Phone:831-637-5536
Mailing Address - Fax:
Practice Address - Street 1:365 6TH ST
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-3834
Practice Address - Country:US
Practice Address - Phone:831-637-5536
Practice Address - Fax:831-637-7601
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9640 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABQ523YMedicare PIN
CAU48999Medicare UPIN