Provider Demographics
NPI:1386637122
Name:ROBERTS, KENRICK HAMILTON (MD)
Entity Type:Individual
Prefix:DR
First Name:KENRICK
Middle Name:HAMILTON
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 1:100 WELTON DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1336
Mailing Address - Country:US
Mailing Address - Phone:301-777-7900
Mailing Address - Fax:301-777-5381
Practice Address - Street 1:100 WELTON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1336
Practice Address - Country:US
Practice Address - Phone:301-777-7900
Practice Address - Fax:301-777-5381
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020835207N00000X
WV10481207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD971511800Medicaid
D74536Medicare UPIN
103L801AMedicare ID - Type Unspecified