Provider Demographics
NPI:1114923083
Name:ROBERTS, DWAYNE LEE (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:LEE
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 1:1201 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4427
Mailing Address - Country:US
Mailing Address - Phone:817-332-2020
Mailing Address - Fax:817-332-4797
Practice Address - Street 1:1201 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-4427
Practice Address - Country:US
Practice Address - Phone:817-332-2020
Practice Address - Fax:817-332-4797
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8921207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166464101Medicaid
TX8J0403OtherBCBS
TX166464102Medicaid
TX166464102Medicaid
TX8C1154Medicare PIN
TX8J0403OtherBCBS
TXP00142066Medicare PIN