Provider Demographics
NPI:1780837914
Name:ROBERTSON, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 MCQUEEN SMITH RD S
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-5631
Mailing Address - Country:US
Mailing Address - Phone:334-365-9911
Mailing Address - Fax:
Practice Address - Street 1:478 MCQUEEN SMITH RD S
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5631
Practice Address - Country:US
Practice Address - Phone:334-365-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009948105Medicaid