Provider Demographics
NPI:1700866282
Name:SKELLEY, ROBERT GERARD (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GERARD
Last Name:SKELLEY
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-0670
Mailing Address - Country:US
Mailing Address - Phone:563-652-5603
Mailing Address - Fax:563-323-0949
Practice Address - Street 1:204 N ARCADE ST
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2022
Practice Address - Country:US
Practice Address - Phone:563-652-5603
Practice Address - Fax:563-323-0949
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA21524OtherBCBS OF IOWA
IA0156133Medicaid
IA37836OtherBCBS OF IOWA
IA2156133Medicaid
IA21524Medicare ID - Type Unspecified
IAT01095Medicare UPIN
IA0156133Medicaid
IA0285000002Medicare NSC