Provider Demographics
NPI:1265746564
Name:ROBERTSON, MELIA RAY (OD)
Entity type:Individual
Prefix:DR
First Name:MELIA
Middle Name:RAY
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELIA
Other - Middle Name:RAY
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2424 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2531
Mailing Address - Country:US
Mailing Address - Phone:479-728-0199
Mailing Address - Fax:479-280-1993
Practice Address - Street 1:2424 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2531
Practice Address - Country:US
Practice Address - Phone:479-728-0199
Practice Address - Fax:479-280-1993
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2649152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist