Provider Demographics
NPI:1578534012
Name:ROBERTS, KRISTY M (DO)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 FOUNTAIN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3684
Mailing Address - Country:US
Mailing Address - Phone:501-932-5060
Mailing Address - Fax:501-552-5330
Practice Address - Street 1:3025 FOUNTAIN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3684
Practice Address - Country:US
Practice Address - Phone:501-932-5060
Practice Address - Fax:501-552-5330
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158728003Medicaid
I44401Medicare UPIN
AR158728003Medicaid
5N394Medicare ID - Type Unspecified