Provider Demographics
NPI:1720094287
Name:ROEBUCK, GEORGE ALBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ALBERT
Last Name:ROEBUCK
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 1:113 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2101
Mailing Address - Country:US
Mailing Address - Phone:815-942-1951
Mailing Address - Fax:815-942-1958
Practice Address - Street 1:113 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-2101
Practice Address - Country:US
Practice Address - Phone:815-942-1951
Practice Address - Fax:815-942-1958
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007227152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03084002OtherBLUE CROSS BLUE SHIELD
ILT37536Medicare UPIN
IL0335980001Medicare NSC
IL03084002OtherBLUE CROSS BLUE SHIELD