Provider Demographics
NPI:1124009550
Name:ROBERTS, RICHARD E (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
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:PO BOX 3027
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98807-3027
Mailing Address - Country:US
Mailing Address - Phone:509-662-7143
Mailing Address - Fax:509-665-4301
Practice Address - Street 1:717 OKOMA DRIVE
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-826-1191
Practice Address - Fax:509-826-1192
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00002019152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013324Medicaid
WA000350659Medicare ID - Type Unspecified
WA2013324Medicaid