Provider Demographics
NPI:1578565859
Name:ROBERTS, LARRY C (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-2544
Mailing Address - Country:US
Mailing Address - Phone:806-510-3376
Mailing Address - Fax:806-510-3379
Practice Address - Street 1:2005 N 2ND AVE STE D
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-2545
Practice Address - Country:US
Practice Address - Phone:806-510-3376
Practice Address - Fax:806-510-3379
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8856207ND0900X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX070002897OtherMEDICARE RAILROAD
TX807985OtherBLUE CROSS BLUE SHIELD
TX037631101Medicaid
TX037631101Medicaid