Provider Demographics
NPI:1467563700
Name:ROBERTS, LISA BETH (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
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 1:143 ARROWHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-7042
Mailing Address - Country:US
Mailing Address - Phone:814-342-5361
Mailing Address - Fax:814-342-2360
Practice Address - Street 1:29 IRVIN DRIVE
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866
Practice Address - Country:US
Practice Address - Phone:814-342-5361
Practice Address - Fax:814-342-2360
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V06960Medicare UPIN