Provider Demographics
NPI:1144493792
Name:ROBERTSON, LAURIE ANN (OD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ANN
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 1:7747 242ND AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9448
Mailing Address - Country:US
Mailing Address - Phone:262-843-2999
Mailing Address - Fax:262-843-2999
Practice Address - Street 1:6125 GREEN BAY RD
Practice Address - Street 2:SUITE 800
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2928
Practice Address - Country:US
Practice Address - Phone:262-654-0726
Practice Address - Fax:262-654-4365
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2564 - 035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU-67194Medicare UPIN