Provider Demographics
NPI:1619077286
Name:ROBERTS, NEIL J (OD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:J
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 1:175 N 400 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1909
Mailing Address - Country:US
Mailing Address - Phone:801-224-6767
Mailing Address - Fax:801-221-1052
Practice Address - Street 1:175 N 400 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1909
Practice Address - Country:US
Practice Address - Phone:801-224-6767
Practice Address - Fax:801-221-1052
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4759492-8904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1447378302OtherGROUP NPI
UT1619077286OtherNPI
UTMR0566060OtherDEA REGISTRATION NUMBER
UT1447378302OtherGROUP NPI
UTU81040Medicare UPIN
UT005541206Medicare ID - Type UnspecifiedMCR NUMBER