Provider Demographics
NPI:1194865576
Name:ROBERTS, EVAN MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:MATTHEW
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 1:2053 CORONADO VW
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-4105
Mailing Address - Country:US
Mailing Address - Phone:619-722-6121
Mailing Address - Fax:
Practice Address - Street 1:BLDG 1103
Practice Address - Street 2:MAIN EXCHANGE COMPLEX
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-385-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8120T152WC0802X, 152W00000X, 152WP0200X, 152WL0500X, 152WV0400X, 152WX0102X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision