Provider Demographics
NPI:1629628102
Name:ROBERTS, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-2007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 SUNSET DR
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-2007
Practice Address - Country:US
Practice Address - Phone:508-533-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE0914422OtherCOMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH