Provider Demographics
NPI:1619327905
Name:ROBERTS, WILLIAM RAFAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RAFAEL
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 1:8 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1157
Mailing Address - Country:US
Mailing Address - Phone:850-218-6527
Mailing Address - Fax:
Practice Address - Street 1:1303 E VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3642
Practice Address - Country:US
Practice Address - Phone:407-870-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist