Provider Demographics
NPI:1568535656
Name:ROBERTS, ALFRED ROY (OD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:ROY
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:A
Other - Middle Name:ROY
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2635 W DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-2605
Mailing Address - Country:US
Mailing Address - Phone:316-942-7496
Mailing Address - Fax:316-239-2557
Practice Address - Street 1:8150 E DOUGLAS AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2376
Practice Address - Country:US
Practice Address - Phone:316-942-7496
Practice Address - Fax:316-239-2557
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1201-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0548150002Medicare NSC
KS651164Medicare PIN
KST77043Medicare UPIN