Provider Demographics
NPI:1275929010
Name:ROBERTS, BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
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 1:229 S MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5725
Mailing Address - Country:US
Mailing Address - Phone:920-832-2783
Mailing Address - Fax:920-832-2635
Practice Address - Street 1:2005 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952
Practice Address - Country:US
Practice Address - Phone:920-832-8500
Practice Address - Fax:920-380-4840
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66817-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine