Provider Demographics
NPI:1194157289
Name:ROBERTS, TERRENCE JAWAAN (OD)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:JAWAAN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:539 GLYNN ST N
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1108
Mailing Address - Country:US
Mailing Address - Phone:678-817-7722
Mailing Address - Fax:678-817-0067
Practice Address - Street 1:539 GLYNN ST N
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:678-817-7722
Practice Address - Fax:678-817-0067
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist