Provider Demographics
NPI:1215934617
Name:ROBERTS, GREGG JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:JOHN
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 1:24953 PASEO DE VALENCIA
Mailing Address - Street 2:BLDG A STE 24A
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4342
Mailing Address - Country:US
Mailing Address - Phone:949-716-5280
Mailing Address - Fax:949-716-5290
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:BLDG A STE 24A
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4342
Practice Address - Country:US
Practice Address - Phone:949-716-5280
Practice Address - Fax:949-716-5290
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6537T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5085460001OtherDMERC
CASD0065370Medicaid
CA06537OtherCALIFORNIA LICENSE
CA06537OtherCALIFORNIA LICENSE
CA5085460001OtherDMERC