Provider Demographics
NPI:1548222169
Name:ROBERTS, KIRK STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:STEPHEN
Last Name:ROBERTS
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 1:3456 W ORANGE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6810
Mailing Address - Country:US
Mailing Address - Phone:714-801-2210
Mailing Address - Fax:
Practice Address - Street 1:3456 W ORANGE AVE STE C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6810
Practice Address - Country:US
Practice Address - Phone:714-801-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP7041T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0175870001OtherDMERC
0175870001OtherDMERC
0P7041Medicare PIN
0175870001OtherDMERC
Y3615Medicare ID - Type Unspecified