Basic Information
| Provider Information | |||||||||
| NPI: | 1427048305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBISON | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 HWY 528 | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870046633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057714883 | ||||||||
| FaxNumber: | 5057714885 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 HWY 528 | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870046633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057714883 | ||||||||
| FaxNumber: | 5057714885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 244 | NM | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | P1466 | 05 | NM | MEDICAID |