Provider Demographics
NPI:1881729069
Name:DISTER, ROBERT EDWARD (OD)
Entity type:Individual
Prefix:PROF
First Name:ROBERT
Middle Name:EDWARD
Last Name:DISTER
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:UNIVERSITY OF CALIFORNIA BERKELEY SCHOOL OF OPTOMETRY
Mailing Address - Street 2:MINOR HALL (MC2020)
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-2020
Mailing Address - Country:US
Mailing Address - Phone:510-643-2999
Mailing Address - Fax:510-643-5109
Practice Address - Street 1:UNIVERSITY OF CALIFORNIA BERKELEY SCHOOL OF OPTOMETRY
Practice Address - Street 2:MINOR HALL (MC2020)
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-2020
Practice Address - Country:US
Practice Address - Phone:510-643-2999
Practice Address - Fax:510-643-5109
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8706T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0087060Medicaid
CAU54492Medicare UPIN
CASD0087060Medicare ID - Type Unspecified