Provider Demographics
NPI:1629171624
Name:ROBERTS, HEATHER J (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 WILSHIRE BLVD
Mailing Address - Street 2:#408
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1733
Mailing Address - Country:US
Mailing Address - Phone:310-477-4727
Mailing Address - Fax:310-477-2001
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:#408
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1733
Practice Address - Country:US
Practice Address - Phone:310-477-4727
Practice Address - Fax:310-477-2001
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG71960207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG71960AMedicare ID - Type Unspecified
F35502Medicare UPIN