Provider Demographics
NPI:1619057064
Name:ROBERTS, JUSTIN W (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 WEST PINE STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1439
Mailing Address - Country:US
Mailing Address - Phone:573-756-8888
Mailing Address - Fax:573-701-9547
Practice Address - Street 1:501 WEST PINE STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-756-8888
Practice Address - Fax:866-291-5617
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004027799207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI25247Medicare UPIN