Provider Demographics
NPI:1962684605
Name:ROBERTS, MARK WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 NC HIGHWAY 42 N STE B
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-7955
Mailing Address - Country:US
Mailing Address - Phone:336-625-2429
Mailing Address - Fax:336-625-9901
Practice Address - Street 1:177 NC HIGHWAY 42 N STE B
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-7955
Practice Address - Country:US
Practice Address - Phone:336-625-2429
Practice Address - Fax:336-625-9901
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306978069OtherASHEBORO OPTOMETRIC VISION NPI
NC1306978069OtherASHEBORO OPTOMETRIC VISION NPI
NC0576940001Medicare NSC