1427240878 NPI number — DR. SHILOH SUZANNE ROBERTS O.D.

Table of content: DR. SHILOH SUZANNE ROBERTS O.D. (NPI 1427240878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427240878 NPI number — DR. SHILOH SUZANNE ROBERTS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
SHILOH
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427240878
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILGORE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75663-8000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-983-2020
Provider Business Mailing Address Fax Number:
903-983-4000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 SIMPSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILMER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75644-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-843-5400
Provider Business Practice Location Address Fax Number:
903-843-5101
Provider Enumeration Date:
08/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7122T , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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