Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | DR.0054821 | CO |
NPI | 1023270733 |
---|---|
Provider Name | Dr. John Mose Roberts JR. |
First Address | Colorado Springs, CO 80924-7021 |
Second Address | Colorado Springs, CO 80924-7021 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2008 |
Last Update Date | 21/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
56571747 | (05) | CO |