Provider Demographics
NPI:1578654265
Name:ROBERTS, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:210 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2432
Mailing Address - Country:US
Mailing Address - Phone:770-887-9171
Mailing Address - Fax:770-887-9180
Practice Address - Street 1:210 HUDSON ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2432
Practice Address - Country:US
Practice Address - Phone:770-887-9171
Practice Address - Fax:770-887-9180
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU98225Medicare UPIN