Provider Demographics
NPI:1316049885
Name:ROBERTSON, JIMMY DEE (OD)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:DEE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 42ND ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-1642
Mailing Address - Country:US
Mailing Address - Phone:406-452-2924
Mailing Address - Fax:406-761-3547
Practice Address - Street 1:701 SMELTER AVE NE
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-1940
Practice Address - Country:US
Practice Address - Phone:406-761-3461
Practice Address - Fax:406-761-3547
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM45325Medicare UPIN