Provider Demographics
NPI:1598703795
Name:ROBERTS, LARRY K (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:K
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:PO BOX 171206
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1206
Mailing Address - Country:US
Mailing Address - Phone:901-765-3212
Mailing Address - Fax:901-765-1727
Practice Address - Street 1:5959 PARK AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5200
Practice Address - Country:US
Practice Address - Phone:901-765-3212
Practice Address - Fax:901-765-1727
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0102962085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR107376001Medicaid
MO202653804Medicaid
TN3038310Medicaid
MS00115911Medicaid
AR107376001Medicaid
TN3038311Medicare PIN