Provider Demographics
NPI:1144410911
Name:ROBERTSON, NIKKI LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:NIKKI
Middle Name:LYNN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 SIX FORKS RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6156
Mailing Address - Country:US
Mailing Address - Phone:919-847-0187
Mailing Address - Fax:919-676-2231
Practice Address - Street 1:3101 SHANNON RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3571
Practice Address - Country:US
Practice Address - Phone:919-493-8508
Practice Address - Fax:919-676-2231
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00004135152W00000X
NC2171152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920321Medicaid
NC0931XOtherBCBS NC
NC6655AMedicare PIN
NC6655CMedicare PIN
NC6655BMedicare PIN
NC0931XOtherBCBS NC
NC5920321Medicaid