Provider Demographics
NPI:1679668198
Name:ROBERTS, MALLORY SANDERFUR (OD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:SANDERFUR
Last Name:ROBERTS
Suffix:
Gender:F
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 411
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:KY
Mailing Address - Zip Code:42327-0411
Mailing Address - Country:US
Mailing Address - Phone:270-273-3000
Mailing Address - Fax:270-273-9252
Practice Address - Street 1:255 MAIN ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:KY
Practice Address - Zip Code:42327-2104
Practice Address - Country:US
Practice Address - Phone:270-273-3000
Practice Address - Fax:270-273-9252
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1421DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77903375Medicaid
KY77014215Medicaid
KY4173890001Medicare NSC
KYU73459Medicare UPIN
KY77014215Medicaid
KY77903375Medicaid