Provider Demographics
NPI:1457330383
Name:ROBERTS, MARK IAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IAN
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 1:3474 N PROSPECTORS RD
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-9872
Mailing Address - Country:US
Mailing Address - Phone:302-538-0929
Mailing Address - Fax:
Practice Address - Street 1:401 BURRO ALY
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540-9647
Practice Address - Country:US
Practice Address - Phone:928-865-7501
Practice Address - Fax:928-865-9186
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10006136207P00000X
AZ45322207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001111501Medicaid
DE001111501Medicaid
DE007103 S72Medicare ID - Type Unspecified
DE0001111501Medicaid