Provider Demographics
NPI:1679527048
Name:ROBERTS, ROBIN ADERHOLD (MD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:ADERHOLD
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 1:6100 SOUTHWEST BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3930
Mailing Address - Country:US
Mailing Address - Phone:817-989-1221
Mailing Address - Fax:
Practice Address - Street 1:6100 SOUTHWEST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-3930
Practice Address - Country:US
Practice Address - Phone:817-989-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089796901Medicaid
TXE18045Medicare UPIN
TX00D36JMedicare ID - Type Unspecified