Provider Demographics
NPI:1568150332
Name:ROBERTS, THOMAS B
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
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 1:2302 ELLSWORTH RD APT 202
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4822
Mailing Address - Country:US
Mailing Address - Phone:530-680-9708
Mailing Address - Fax:
Practice Address - Street 1:2302 ELLSWORTH RD APT 202
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-4822
Practice Address - Country:US
Practice Address - Phone:530-680-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program