Provider Demographics
NPI:1114911880
Name:ROBERTS, ANTOINE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTOINE
Middle Name:
Last Name:ROBERTS
Suffix:
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 1:4644 LINCOLN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6313
Mailing Address - Country:US
Mailing Address - Phone:310-577-8500
Mailing Address - Fax:310-577-8507
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-577-8500
Practice Address - Fax:310-577-8507
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39726207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG39726Medicare ID - Type Unspecified
CAA922113Medicare UPIN