Provider Demographics
NPI:1629032768
Name:ROBERTS, JERRY TED (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:TED
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 STONE RD
Mailing Address - Street 2:SUITE 2020
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-5482
Mailing Address - Country:US
Mailing Address - Phone:903-983-2020
Mailing Address - Fax:903-983-4000
Practice Address - Street 1:1100 STONE RD
Practice Address - Street 2:SUITE 2020
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5482
Practice Address - Country:US
Practice Address - Phone:903-983-2020
Practice Address - Fax:903-983-4000
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX2344TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168830001OtherCIGNA GOVERNMENT
TX83381EOtherBLUE CROSS BLUE SHIELD
TX019369001Medicaid
TX410022897OtherPALMETTO GBA RAILROAD MED
TX168830001OtherCIGNA GOVERNMENT
TX410022897OtherPALMETTO GBA RAILROAD MED