Provider Demographics
NPI:1922265388
Name:ROBERTS, JAMES EDWARD (LDO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7685 NORTHWOODS BLVD
Mailing Address - Street 2:SUITE 8F
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-4002
Mailing Address - Country:US
Mailing Address - Phone:843-797-2090
Mailing Address - Fax:843-797-3822
Practice Address - Street 1:7685 NORTHWOODS BLVD
Practice Address - Street 2:SUITE 8F
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4002
Practice Address - Country:US
Practice Address - Phone:843-797-2090
Practice Address - Fax:843-797-3822
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC172156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1235347659Medicaid
SCVA 9967Medicaid
SCDV 1720Medicaid