Provider Demographics
NPI:1124230172
Name:ROBERTS, TIMOTHY DALE (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DALE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2477 STICKNEY POINT RD
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-4076
Mailing Address - Country:US
Mailing Address - Phone:941-923-2567
Mailing Address - Fax:941-925-4334
Practice Address - Street 1:2477 STICKNEY POINT RD
Practice Address - Street 2:SUITE 202A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-4076
Practice Address - Country:US
Practice Address - Phone:941-923-2567
Practice Address - Fax:941-925-4334
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7321111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88316OtherBLUE CROSS
FL88316OtherBLUE CROSS