Provider Demographics
NPI:1578635371
Name:ROBERTS, ANDREW B (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
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 1:3530 E SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2209
Mailing Address - Country:US
Mailing Address - Phone:719-296-9000
Mailing Address - Fax:719-296-9001
Practice Address - Street 1:3530 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2209
Practice Address - Country:US
Practice Address - Phone:719-296-9000
Practice Address - Fax:719-296-9001
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CO52254174400000X
CO62254208VP0014X
AZ56140208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ56140OtherARIZONA MEDICAL LICENSE
LA1819468Medicaid
MS09785716Medicaid
LAH61849Medicare UPIN
LA4K534Medicare PIN