Provider Demographics
NPI:1447228663
Name:ROBERTS, RANDY D (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:D
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 1:1000 C EAST MATTHEWS
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401
Mailing Address - Country:US
Mailing Address - Phone:870-268-8880
Mailing Address - Fax:870-268-8882
Practice Address - Street 1:1000 C EAST MATTHEWS
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-268-8880
Practice Address - Fax:870-268-8882
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6752207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110866001Medicaid
54438Medicare ID - Type Unspecified
AR110866001Medicaid