Provider Demographics
NPI:1245420595
Name:ROBERTSON, KENT MITCHELL (OD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:MITCHELL
Last Name:ROBERTSON
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 1:409 MURRY ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301-1948
Mailing Address - Country:US
Mailing Address - Phone:775-289-2580
Mailing Address - Fax:775-289-2566
Practice Address - Street 1:409 MURRY ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-1948
Practice Address - Country:US
Practice Address - Phone:775-289-2580
Practice Address - Fax:775-289-2566
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV 257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002517100Medicaid
U13364Medicare UPIN