Provider Demographics
NPI:1598843815
Name:ROBERTS, GARY L (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
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 1:2035 KING DR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-2538
Mailing Address - Country:US
Mailing Address - Phone:724-981-3010
Mailing Address - Fax:
Practice Address - Street 1:2151 SHENANGO VALLEY FWY
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-2586
Practice Address - Country:US
Practice Address - Phone:724-346-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARO285019Medicare ID - Type Unspecified