Provider Demographics
NPI:1861409021
Name:ROBERSON, JAMES GREGORY (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GREGORY
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:ROCKY
Other - Middle Name:
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-1599
Mailing Address - Country:US
Mailing Address - Phone:405-224-5342
Mailing Address - Fax:
Practice Address - Street 1:619 W CHICKASHA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2413
Practice Address - Country:US
Practice Address - Phone:405-224-5342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100762770AMedicaid
OK100762770AMedicaid
OKU50859Medicare UPIN
OK242411400Medicare ID - Type Unspecified