Provider Demographics
NPI:1336121540
Name:ROBERSON, LEROY SIMONS (OD)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:SIMONS
Last Name:ROBERSON
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 1:29 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-3886
Mailing Address - Country:US
Mailing Address - Phone:828-456-8361
Mailing Address - Fax:828-452-4527
Practice Address - Street 1:29 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-3886
Practice Address - Country:US
Practice Address - Phone:828-456-8361
Practice Address - Fax:828-452-4527
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0928152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09774OtherBC/BS
NC22-70673OtherUHC
NC8909774Medicaid
NC1336121540OtherNPI
NC09774OtherBC/BS
NCT64793Medicare UPIN