Provider Demographics
NPI:1821327677
Name:JEFFREY ROBERTSON
Entity Type:Organization
Organization Name:JEFFREY ROBERTSON
Other - Org Name:JEFFREY W ROBERTSON OD
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-539-5291
Mailing Address - Street 1:PO BOX 1976
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23439-1976
Mailing Address - Country:US
Mailing Address - Phone:757-539-5291
Mailing Address - Fax:757-539-8505
Practice Address - Street 1:418 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4425
Practice Address - Country:US
Practice Address - Phone:757-539-5291
Practice Address - Fax:757-539-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty