Provider Demographics
NPI:1003874108
Name:ROBERTS, JAY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77920 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 6-1
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-3406
Mailing Address - Country:US
Mailing Address - Phone:760-200-3336
Mailing Address - Fax:760-200-0026
Practice Address - Street 1:77920 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 6-1
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-3406
Practice Address - Country:US
Practice Address - Phone:760-200-3336
Practice Address - Fax:760-200-0026
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40665208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C406650OtherBLUE SHIELD OF CA
CAA37424Medicare UPIN
CAOOC406651Medicare PIN