Provider Demographics
NPI:1952593311
Name:ROBERTS, JADIE BOLTON (OD)
Entity Type:Individual
Prefix:DR
First Name:JADIE
Middle Name:BOLTON
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:PO BOX 8000
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75663-8000
Mailing Address - Country:US
Mailing Address - Phone:903-983-2020
Mailing Address - Fax:903-983-4000
Practice Address - Street 1:1100 STONE RD
Practice Address - Street 2:SUITE 2020
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5482
Practice Address - Country:US
Practice Address - Phone:903-983-2020
Practice Address - Fax:903-983-4000
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7123T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist