Provider Demographics
NPI:1295863504
Name:ROBERTS, CHAD (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
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:PO BOX 8460
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8460
Mailing Address - Country:US
Mailing Address - Phone:307-733-4905
Mailing Address - Fax:307-733-4906
Practice Address - Street 1:110 BUFFALO WAY
Practice Address - Street 2:STE A
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-733-4905
Practice Address - Fax:307-733-4906
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY289T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist