Provider Demographics
NPI:1629395405
Name:ROBERTS, JERRY THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:THOMAS
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 TRADEPARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3428
Mailing Address - Country:US
Mailing Address - Phone:606-679-2773
Mailing Address - Fax:606-679-4626
Practice Address - Street 1:117 TRADEPARK DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3428
Practice Address - Country:US
Practice Address - Phone:606-679-2773
Practice Address - Fax:606-679-4626
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPOD001206213ES0103X
KY00439213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program