Provider Demographics
NPI:1720073869
Name:ROBERTSON, JEFFREY (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:ROBERTSON
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 1:102 WINTERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-7669
Mailing Address - Country:US
Mailing Address - Phone:757-539-0615
Mailing Address - Fax:
Practice Address - Street 1:115 COLISEUM XING SPC 58
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5971
Practice Address - Country:US
Practice Address - Phone:757-751-6236
Practice Address - Fax:757-838-1840
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2016-08-21
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
VA0618000334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9204300Medicaid
VA9204300Medicaid
VA580947829Medicare PIN