Provider Demographics
NPI:1609854421
Name:ROBERTS, KEVIN W (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 EAST AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WOODSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08098-1351
Mailing Address - Country:US
Mailing Address - Phone:856-769-2800
Mailing Address - Fax:856-769-4256
Practice Address - Street 1:125 EAST AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WOODSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08098-1351
Practice Address - Country:US
Practice Address - Phone:856-769-2800
Practice Address - Fax:856-769-4256
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA05112100207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJB09578Medicare UPIN
NJ040605MYFMedicare PIN