Provider Demographics
NPI:1053447292
Name:ROBERTI, PAUL LOUIS (MS ATC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:LOUIS
Last Name:ROBERTI
Suffix:
Gender:M
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 CUSHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-3014
Mailing Address - Country:US
Mailing Address - Phone:401-434-7795
Mailing Address - Fax:
Practice Address - Street 1:61 CUSHMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-3014
Practice Address - Country:US
Practice Address - Phone:401-434-7795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1002Medicare UPIN