Provider Demographics
NPI:1265503320
Name:ROBERTSON, RODGER DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RODGER
Middle Name:DEAN
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 1:213 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2700
Practice Address - Country:US
Practice Address - Phone:208-882-2932
Practice Address - Fax:208-882-8776
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805042600Medicaid
ID1209170001Medicare NSC
IDT-60771Medicare UPIN
ID1593046Medicare ID - Type Unspecified