Provider Demographics
NPI:1063694412
Name:JOHN D ROBERTS MDPC
Entity type:Organization
Organization Name:JOHN D ROBERTS MDPC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-9767
Mailing Address - Street 1:917 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6759
Mailing Address - Country:US
Mailing Address - Phone:478-374-9767
Mailing Address - Fax:478-374-9769
Practice Address - Street 1:917 PLAZA AVE
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6759
Practice Address - Country:US
Practice Address - Phone:478-374-9767
Practice Address - Fax:478-374-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047253332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4101390001Medicare NSC