Provider Demographics
NPI:1134113574
Name:JARRELL, ROBERT LEE JR (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:JARRELL
Suffix:JR
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 1:3901 GEORGIA ST NE
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1359
Mailing Address - Country:US
Mailing Address - Phone:505-883-4200
Mailing Address - Fax:505-889-2748
Practice Address - Street 1:3901 GEORGIA ST NE
Practice Address - Street 2:SUITE A-2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1359
Practice Address - Country:US
Practice Address - Phone:505-883-4200
Practice Address - Fax:505-889-2748
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP0227Medicaid
NMP0227Medicaid
NM2590868Medicare PIN