Provider Demographics
NPI:1730118878
Name:KOCEMBO, ROBERT THOMAS JR (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:THOMAS
Last Name:KOCEMBO
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:40566 ALDEN RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2852
Mailing Address - Country:US
Mailing Address - Phone:313-719-8967
Mailing Address - Fax:313-259-6006
Practice Address - Street 1:40566 ALDEN RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2852
Practice Address - Country:US
Practice Address - Phone:313-719-8967
Practice Address - Fax:313-259-6006
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI4901003146152W00000X
IN18003828A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist