Provider Demographics
NPI:1386663979
Name:ROBERTS, RONALD EARL JR (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:EARL
Last Name:ROBERTS
Suffix:JR
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 1:2195 HARRODSBURG RD STE 125
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3504
Mailing Address - Country:US
Mailing Address - Phone:859-323-6793
Mailing Address - Fax:
Practice Address - Street 1:202 BEVINS LN
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-6178
Practice Address - Country:US
Practice Address - Phone:859-323-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32142208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCB5773OtherRR MEDICARE GROUP
KY64321425Medicaid
KY4000501OtherMEDICARE LAB GROUP
KY110244643OtherRR MEDICARE PIN
KY64321425Medicaid
KY110244643OtherRR MEDICARE PIN
H08645Medicare UPIN