Provider Demographics
NPI:1992714307
Name:ROBINSON, JACK STEVEN (OD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:STEVEN
Last Name:ROBINSON
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 1:711 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-1575
Mailing Address - Country:US
Mailing Address - Phone:215-257-8053
Mailing Address - Fax:215-257-2020
Practice Address - Street 1:711 LAWN AVE
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1575
Practice Address - Country:US
Practice Address - Phone:215-257-8053
Practice Address - Fax:215-257-2020
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000368152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015204440002Medicaid
PA410045111OtherRAILROAD MEDICARE
PAT72753Medicare UPIN
PA433887Medicare ID - Type Unspecified