Provider Demographics
NPI:1427045921
Name:ROBERTS, DAVID L (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
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:PO BOX 829
Mailing Address - Street 2:POTEAU
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0829
Mailing Address - Country:US
Mailing Address - Phone:918-647-3284
Mailing Address - Fax:918-647-3394
Practice Address - Street 1:2110 N BROADWAY ST
Practice Address - Street 2:POTEAU
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2501
Practice Address - Country:US
Practice Address - Phone:918-647-3284
Practice Address - Fax:918-647-3394
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731508474953A001OtherTRICARE STANDARD
OK100761880AMedicaid
OK100761880AMedicaid
OKP00082080Medicare PIN
OKT40625Medicare UPIN
OK731508478Medicare ID - Type UnspecifiedMEDICARE (UMWA)
OK0249680001Medicare NSC