Provider Demographics
NPI:1831179175
Name:ROBERTS, GEORGE L (OD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
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 1:100 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SCHUYLKILL HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17972-1677
Mailing Address - Country:US
Mailing Address - Phone:570-385-2345
Mailing Address - Fax:570-385-2345
Practice Address - Street 1:100 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:SCHUYLKILL HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17972
Practice Address - Country:US
Practice Address - Phone:570-385-2345
Practice Address - Fax:570-385-2345
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000046152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAROB71481Medicare ID - Type Unspecified
PAT28156Medicare UPIN