Provider Demographics
NPI:1093778003
Name:ROBERTS, ROGER W (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-2504
Mailing Address - Country:US
Mailing Address - Phone:620-343-6800
Mailing Address - Fax:
Practice Address - Street 1:1301 W 12TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-2590
Practice Address - Country:US
Practice Address - Phone:620-343-2376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0317701207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060030783OtherRAILROAD MEDICARE
KS100098630CMedicaid
KS047716Medicare PIN
KS100098630CMedicaid