Provider Demographics
NPI:1164535019
Name:HUMPHREY, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HUMPHREY
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 1:976 MCLEAN AVE
Mailing Address - Street 2:SUITE 387
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-4105
Mailing Address - Country:US
Mailing Address - Phone:914-237-6797
Mailing Address - Fax:914-206-4950
Practice Address - Street 1:1338 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2034
Practice Address - Country:US
Practice Address - Phone:310-255-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG029748174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC402ZMedicare PIN
CADC402YMedicare PIN
CAWG29748BMedicare PIN