Provider Demographics
NPI:1437210614
Name:ROBERTS, JOHN AUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:AUSTIN
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 1:4791 E PALM CANYON DR
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-5220
Mailing Address - Country:US
Mailing Address - Phone:760-834-7950
Mailing Address - Fax:
Practice Address - Street 1:4791 E PALM CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-5220
Practice Address - Country:US
Practice Address - Phone:760-834-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG765502084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30740100Medicaid
WI30740100Medicaid
WI84310Medicare ID - Type Unspecified