Provider Demographics
NPI:1942577879
Name:DORTHEANNE J. ROBERTS, OD PA
Entity type:Organization
Organization Name:DORTHEANNE J. ROBERTS, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DORTHEANNE
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-252-5426
Mailing Address - Street 1:1486 WATER PIPIT LN
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7238
Mailing Address - Country:US
Mailing Address - Phone:904-252-5426
Mailing Address - Fax:
Practice Address - Street 1:401 BAY ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4109
Practice Address - Country:US
Practice Address - Phone:904-529-9062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty