Provider Demographics
NPI:1275577264
Name:ROBERTS, DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
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 1:5835 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7001
Mailing Address - Country:US
Mailing Address - Phone:405-604-9595
Mailing Address - Fax:405-634-7577
Practice Address - Street 1:5835 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7001
Practice Address - Country:US
Practice Address - Phone:405-604-9595
Practice Address - Fax:405-634-7577
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100064450AMedicaid
OK100064450CMedicaid
OK243435205Medicare PIN
OK900522214Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
OK100064450CMedicaid