Provider Demographics
NPI:1023179702
Name:ROBERTS, WILLIAM MICHAEL (CPO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 PORTLAND RD NE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1684
Mailing Address - Country:US
Mailing Address - Phone:503-390-6992
Mailing Address - Fax:503-390-6992
Practice Address - Street 1:4660 PORTLAND RD NE
Practice Address - Street 2:SUITE 107
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1684
Practice Address - Country:US
Practice Address - Phone:503-390-6992
Practice Address - Fax:503-390-6992
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067686Medicaid
OR067686Medicaid