Provider Demographics
NPI:1912997941
Name:ROBERTS, MARGARET L (OD)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
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 302
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083-0302
Mailing Address - Country:US
Mailing Address - Phone:615-666-6004
Mailing Address - Fax:615-666-6004
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-1225
Practice Address - Country:US
Practice Address - Phone:615-666-6004
Practice Address - Fax:615-666-6004
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD467152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3590704Medicare ID - Type Unspecified
TN0668490001Medicare NSC
TNU30188Medicare UPIN