Provider Demographics
NPI:1295833119
Name:ROBERTSON, STANLEY W (OD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:W
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:RR 2 BOX 524-E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-9627
Mailing Address - Country:US
Mailing Address - Phone:304-487-3787
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 524-E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-9627
Practice Address - Country:US
Practice Address - Phone:304-487-3787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV584D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist