Provider Demographics
NPI:1568763738
Name:ROBERTS, CORNELL DUPREE
Entity Type:Individual
Prefix:MR
First Name:CORNELL
Middle Name:DUPREE
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:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638-0094
Mailing Address - Country:US
Mailing Address - Phone:410-490-6552
Mailing Address - Fax:
Practice Address - Street 1:601 LOCUST ST STE 203
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1720
Practice Address - Country:US
Practice Address - Phone:410-490-6552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$AMedicare PIN