Provider Demographics
NPI:1376561050
Name:ROBERTS, ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
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 1:5901 WEST OLYMPIC BLVD
Mailing Address - Street 2:100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036
Mailing Address - Country:US
Mailing Address - Phone:323-930-1332
Mailing Address - Fax:323-930-1354
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-930-1332
Practice Address - Fax:323-930-1354
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA17567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA20956Medicare UPIN
CAA17567Medicare ID - Type Unspecified