Provider Demographics
NPI:1609031533
Name:SELLERS, ROBERT SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SCOTT
Last Name:SELLERS
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:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-1257
Mailing Address - Country:US
Mailing Address - Phone:928-792-4455
Mailing Address - Fax:928-792-4463
Practice Address - Street 1:3383 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:THATCHER
Practice Address - State:AZ
Practice Address - Zip Code:85552
Practice Address - Country:US
Practice Address - Phone:928-792-4455
Practice Address - Fax:928-792-4463
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1628152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ352532Medicaid