Basic Information
| Provider Information | |||||||||
| NPI: | 1972665883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636872260 | ||||||||
| FaxNumber: | 8635950927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 04/09/2016 | ||||||||
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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 | 152WC0802X | OPC2385 | FL | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | 8843-T | CA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPC2385 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 11840789 | 01 | CAQH | OTHER | V12404 | 01 | UPIN | OTHER |