Provider Demographics
NPI:1669477295
Name:ROBERTS, REUBEN S (MD)
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:S
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:PO BOX 1237
Mailing Address - Street 2:492 LOWER RIVER ROAD
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7237
Mailing Address - Country:US
Mailing Address - Phone:478-783-4549
Mailing Address - Fax:478-783-4529
Practice Address - Street 1:492 LOWER RIVER RD
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-6412
Practice Address - Country:US
Practice Address - Phone:478-783-4549
Practice Address - Fax:478-783-4529
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000089537BMedicaid
E58941Medicare UPIN
GA08BDFFFMedicare ID - Type Unspecified