Provider Demographics
NPI:1467893800
Name:DR. JOHN D. ROBERTS, OD PSC
Entity Type:Organization
Organization Name:DR. JOHN D. ROBERTS, OD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-351-8661
Mailing Address - Street 1:472 W LINCOLN TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2047
Mailing Address - Country:US
Mailing Address - Phone:270-351-8661
Mailing Address - Fax:270-351-8713
Practice Address - Street 1:472 W LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2047
Practice Address - Country:US
Practice Address - Phone:270-351-8661
Practice Address - Fax:270-351-8713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1048DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010486Medicaid
KY77010486Medicaid