Provider Demographics
NPI:1942499660
Name:DAVID L ROBERTS O D P C
Entity Type:Organization
Organization Name:DAVID L ROBERTS O D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-647-3284
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0829
Mailing Address - Country:US
Mailing Address - Phone:918-647-3284
Mailing Address - Fax:918-647-3394
Practice Address - Street 1:2110 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2501
Practice Address - Country:US
Practice Address - Phone:918-647-3284
Practice Address - Fax:918-647-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK781152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100761880AMedicaid
731508474953A001OtherTRICARE
OK441409440001OtherBCBS
731508474953A001OtherTRICARE
OK=========OtherCOMMERCIAL INS
OKT40625Medicare UPIN
OKDR2936Medicare PIN
OK0249680001Medicare NSC