Provider Demographics
NPI:1164417846
Name:ROBERTS, CHARLES RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAY
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 1:1181 E FRY BLVD
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2669
Mailing Address - Country:US
Mailing Address - Phone:520-458-3241
Mailing Address - Fax:520-378-1176
Practice Address - Street 1:1181 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2669
Practice Address - Country:US
Practice Address - Phone:520-458-3241
Practice Address - Fax:520-378-1176
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T91304Medicare UPIN
AZ41WCHPL02Medicare ID - Type Unspecified