Basic Information
Provider Information | |||||||||
NPI: | 1376521831 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | JOAN | ||||||||
MiddleName: | THERESE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4102 N ROXBORO ST | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277042122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195952000 | ||||||||
FaxNumber: | 9195952190 | ||||||||
Practice Location | |||||||||
Address1: | 4102 N ROXBORO ST | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277042122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195952000 | ||||||||
FaxNumber: | 9195952190 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2006 | ||||||||
LastUpdateDate: | 10/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 9401000 | NC | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 72175 | 01 | NC | BCBSNC | OTHER | 8972175 | 05 | NC |   | MEDICAID | 19535 | 01 | NC | OPTICARE | OTHER | 5612887674 | 01 | NC | CIGNA | OTHER | 0852210 | 01 | NC | UNITED HEALTHCARE | OTHER | 23492 | 01 | NC | PARTNERS | OTHER | 429966 | 01 | NC | MAMSI | OTHER | 52203 | 01 | NC | MEDCOST | OTHER | 4540511 | 01 | NC | AETNA PPO | OTHER | 2442919 | 01 | NC | AETNA HMO | OTHER |