Provider Demographics
NPI:1073518254
Name:ROBERTS, LEROY JR (MD)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:ROBERTS
Suffix:JR
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 1:3186 VILLAGE DR 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3979
Mailing Address - Country:US
Mailing Address - Phone:910-486-5700
Mailing Address - Fax:910-486-5950
Practice Address - Street 1:3186 VILLAGE DR 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3979
Practice Address - Country:US
Practice Address - Phone:910-486-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC309892085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8972464Medicaid
2146953Medicare ID - Type Unspecified
E39279Medicare UPIN