Provider Demographics
NPI:1619902822
Name:POWELSON, ROBERT WILLIAM
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:POWELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:SHINNSTON
Mailing Address - State:WV
Mailing Address - Zip Code:26431-1405
Mailing Address - Country:US
Mailing Address - Phone:304-592-1500
Mailing Address - Fax:304-592-1343
Practice Address - Street 1:401 PIKE ST
Practice Address - Street 2:
Practice Address - City:SHINNSTON
Practice Address - State:WV
Practice Address - Zip Code:26431-1405
Practice Address - Country:US
Practice Address - Phone:304-592-1500
Practice Address - Fax:304-592-1343
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV763OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150761000Medicaid
WV0280170001Medicare NSC
WV9247621Medicare PIN
WV0280170002Medicare NSC
WV0150761000Medicaid
WV9195332Medicare PIN