Provider Demographics
NPI:1467737411
Name:ROBERTS, CLARENCE ALVIN JR (DPH)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:ALVIN
Last Name:ROBERTS
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 N LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74110-0746
Mailing Address - Country:US
Mailing Address - Phone:918-583-7593
Mailing Address - Fax:
Practice Address - Street 1:1438 N LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-0746
Practice Address - Country:US
Practice Address - Phone:918-583-7593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist