Provider Demographics
NPI:1417923574
Name:WEINTRAUT, ROBERTA (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:WEINTRAUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 EISENHOWER PKWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-0800
Mailing Address - Country:US
Mailing Address - Phone:478-633-5500
Mailing Address - Fax:478-784-3550
Practice Address - Street 1:3780 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-0800
Practice Address - Country:US
Practice Address - Phone:478-633-5500
Practice Address - Fax:478-784-3550
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000553572EMedicaid
GAF63623Medicare UPIN
GA08BBXCPMedicare ID - Type Unspecified