Provider Demographics
NPI:1649208844
Name:ROBERTS, TODD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ALAN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 196TH
Mailing Address - Street 2:
Mailing Address - City:PLEASANT DALE
Mailing Address - State:NE
Mailing Address - Zip Code:68423-9118
Mailing Address - Country:US
Mailing Address - Phone:402-826-5937
Mailing Address - Fax:
Practice Address - Street 1:2300 S 16TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3704
Practice Address - Country:US
Practice Address - Phone:402-481-8644
Practice Address - Fax:402-481-3061
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA64654207P00000X
NE24600207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024951-00Medicaid
NJ7152604Medicaid
NE099338012Medicare PIN
NJ7152604Medicaid
G42556Medicare UPIN