Provider Demographics
NPI:1972665883
Name:ROBERTS, DAVID A (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1251 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4673
Practice Address - Country:US
Practice Address - Phone:863-687-2260
Practice Address - Fax:863-595-0927
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2385152WC0802X, 152W00000X
CA8843-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
11840789OtherCAQH
V12404OtherUPIN