Provider Demographics
NPI:1033672605
Name:ROBERTS, DUSTIN GELDRICH
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:GELDRICH
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 VETERAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4523
Mailing Address - Country:US
Mailing Address - Phone:714-604-6096
Mailing Address - Fax:
Practice Address - Street 1:1847 VETERAN AVE APT 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4523
Practice Address - Country:US
Practice Address - Phone:714-604-6096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program