Provider Demographics
NPI:1215912464
Name:ROBERTS, JERRY D (OD)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:D
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 1:279 N GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170
Mailing Address - Country:US
Mailing Address - Phone:812-752-5106
Mailing Address - Fax:812-752-5132
Practice Address - Street 1:279 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170
Practice Address - Country:US
Practice Address - Phone:812-752-5106
Practice Address - Fax:812-752-5132
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001504A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100099460BMedicaid
005120OtherSIHO
410010037OtherRR MEDICARE
000000109053OtherANTHEM
005120OtherSIHO
410010037OtherRR MEDICARE