Provider Demographics
NPI:1861826141
Name:ROBERSON, DANIEL KEITH (OD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:KEITH
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3706
Mailing Address - Country:US
Mailing Address - Phone:262-880-5203
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-5440
Practice Address - Fax:224-610-7150
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3320-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist