Provider Demographics
NPI:1104828821
Name:ROBERTS, BRUCE JOHN (MD, FACOG)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:JOHN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD, FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:C-234
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-7711
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:C-234
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8605207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC21124Medicare UPIN
TX812723Medicare PIN