Provider Demographics
NPI:1740458744
Name:DR.MARK D.ROBERTSON,OD
Entity type:Organization
Organization Name:DR.MARK D.ROBERTSON,OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-661-0924
Mailing Address - Street 1:2701 DAVID MCLEOD BLVD
Mailing Address - Street 2:C/O LENSCRAFTERS
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4028
Mailing Address - Country:US
Mailing Address - Phone:843-661-0924
Mailing Address - Fax:843-661-0926
Practice Address - Street 1:2701 DAVID MCLEOD BOULEVARD
Practice Address - Street 2:C/O LENSCRAFTERS
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4028
Practice Address - Country:US
Practice Address - Phone:843-661-0924
Practice Address - Fax:843-661-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC08874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty