Provider Demographics
NPI:1720142466
Name:ROBERTSON, MARK DAVIS (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVIS
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:PO BOX 503900
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950-3900
Mailing Address - Country:US
Mailing Address - Phone:670-235-9090
Mailing Address - Fax:670-235-9091
Practice Address - Street 1:503900 MOOTY 13 FISHERMEN BEACHROAD, GARAPAN
Practice Address - Street 2:
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-3900
Practice Address - Country:US
Practice Address - Phone:670-235-9090
Practice Address - Fax:670-235-9091
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP0015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP54299Medicare PIN