Provider Demographics
NPI:1598732521
Name:ROBERTS, KENNETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
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 1:2812 HARTFORD HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4927
Mailing Address - Country:US
Mailing Address - Phone:334-712-1170
Mailing Address - Fax:334-460-8391
Practice Address - Street 1:1970 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3726
Practice Address - Country:US
Practice Address - Phone:334-774-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.9562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL162537Medicaid
AL166960Medicaid