Provider Demographics
NPI:1851663512
Name:OPTIC ART III, PLLC
Entity Type:Organization
Organization Name:OPTIC ART III, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RODGER
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-882-2932
Mailing Address - Street 1:213 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2700
Mailing Address - Country:US
Mailing Address - Phone:208-882-2932
Mailing Address - Fax:
Practice Address - Street 1:213 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2700
Practice Address - Country:US
Practice Address - Phone:208-882-2932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805042600Medicaid
IDT-60771Medicare UPIN
ID805042600Medicaid
ID1209170001Medicare NSC