Provider Demographics
NPI:1356590525
Name:ROBERTS, KEITH A (OD)
Entity type:Individual
Prefix:
First Name:KEITH
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 1:5855 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0058
Mailing Address - Country:US
Mailing Address - Phone:812-288-2029
Mailing Address - Fax:502-736-4490
Practice Address - Street 1:5855 RELIABLE PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60686-0001
Practice Address - Country:US
Practice Address - Phone:812-288-2029
Practice Address - Fax:502-736-4490
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1735DT152W00000X
IN18003510A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100079400Medicaid
IN200922030Medicaid
IN200922030Medicaid
KY5375220004Medicare NSC
IN5375220001Medicare NSC
KY0959012Medicare PIN