Provider Demographics
NPI:1366445835
Name:ROBERTS, JON A (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7695 POPLAR PIKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-5947
Mailing Address - Country:US
Mailing Address - Phone:901-685-2696
Mailing Address - Fax:901-682-9747
Practice Address - Street 1:7695 POPLAR PIKE
Practice Address - Street 2:SUITE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138-5947
Practice Address - Country:US
Practice Address - Phone:901-685-2696
Practice Address - Fax:901-682-9747
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN216722085R0202X, 2085R0204X
MS134482085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3061916Medicaid
TNF02274Medicare UPIN
TN3061916Medicaid
TN3061912Medicare PIN