Provider Demographics
NPI:1427105972
Name:ROBERTS, RICHARD DAVID (OPTICIAN)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HIGHTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-3300
Mailing Address - Country:US
Mailing Address - Phone:609-448-0970
Mailing Address - Fax:
Practice Address - Street 1:122 MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGHTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08520-3300
Practice Address - Country:US
Practice Address - Phone:609-448-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD001176156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0695850001Medicare NSC