Provider Demographics
NPI:1508869926
Name:ROBERTS, DOUGLAS E JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:ROBERTS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:900 N HERITAGE DR
Mailing Address - Street 2:BLDG E
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-5536
Mailing Address - Country:US
Mailing Address - Phone:760-446-4571
Mailing Address - Fax:760-446-0970
Practice Address - Street 1:900 N HERITAGE DR
Practice Address - Street 2:BLDG E
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-5536
Practice Address - Country:US
Practice Address - Phone:760-446-4571
Practice Address - Fax:760-446-0970
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35606207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G356060OtherBLUE SHIELD
CA0103OtherJOHN DEERE
CA00G356060Medicaid
00G356060OtherCOMMERCIAL INS.
0616650001OtherDME
93555B036OtherWPS TRICARE
00G356060OtherBLUE CROSS
110039741OtherRAILROAD MEDICARE
110039741OtherRAILROAD MEDICARE
AR1061908OtherDEA
CA00G356060Medicaid