Provider Demographics
NPI:1427000397
Name:ROBERTS, ELIZABETH A (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 WASHINGTON SQ
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3257
Mailing Address - Country:US
Mailing Address - Phone:651-429-3379
Mailing Address - Fax:651-429-8681
Practice Address - Street 1:4750 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3257
Practice Address - Country:US
Practice Address - Phone:651-429-3379
Practice Address - Fax:651-429-8681
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110387OtherUCARE
MN2201001OtherMEDICA
MNHP19487OtherHEALTH PARTNERS
MN1010370OtherPREFERRED ONE
MN4C748ROOtherBLUE CROSS BLUE SHIELD
MN2201001OtherMEDICA