Provider Demographics
NPI:1437395571
Name:ROBERTS, LONNIE D
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19816 ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637
Mailing Address - Country:US
Mailing Address - Phone:574-273-2343
Mailing Address - Fax:574-272-4752
Practice Address - Street 1:19816 ADAMS RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-1620
Practice Address - Country:US
Practice Address - Phone:574-273-2343
Practice Address - Fax:574-272-4752
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200888720AMedicaid