Provider Demographics
NPI:1467435883
Name:ROBERTS, LORI RENE (O D)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:RENE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 DOUGHERTY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6017
Mailing Address - Country:US
Mailing Address - Phone:803-617-7611
Mailing Address - Fax:803-761-7720
Practice Address - Street 1:967 DOUGHERTY RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6017
Practice Address - Country:US
Practice Address - Phone:803-617-7611
Practice Address - Fax:803-761-7720
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13073Medicaid
SCAA03807943Medicare PIN
SC5195810001Medicare NSC
SCD13073Medicaid