Provider Demographics
NPI:1104828417
Name:ROBERTS, JAMES C SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:C
Last Name:ROBERTS
Suffix:SR
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 1:10942 WINSLOW RD.
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43571
Mailing Address - Country:US
Mailing Address - Phone:419-877-9171
Mailing Address - Fax:
Practice Address - Street 1:5923 RENAISSANCE PLACE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623
Practice Address - Country:US
Practice Address - Phone:419-824-5067
Practice Address - Fax:419-824-5457
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35020439174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0046891Medicaid
OH0046891Medicaid