Provider Demographics
NPI:1679659213
Name:ROBERTS, MARK A (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:415 BARNWELL AVE NW
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801
Mailing Address - Country:US
Mailing Address - Phone:803-644-4403
Mailing Address - Fax:803-644-4405
Practice Address - Street 1:415 BARNWELL AVE NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-644-4403
Practice Address - Fax:803-644-4405
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC020863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT38368Medicaid
SC020863OtherMED BD LLR
SC020863OtherMED BD LLR
C72751Medicare UPIN