Provider Demographics
NPI:1689618886
Name:ROBERTS, WILLIAM JOSEPH (MD PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD PHD
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 550
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763
Mailing Address - Country:US
Mailing Address - Phone:865-376-6518
Mailing Address - Fax:865-376-9544
Practice Address - Street 1:1445 KINGSTON WAY
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763
Practice Address - Country:US
Practice Address - Phone:865-376-6518
Practice Address - Fax:865-376-9544
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD015025208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A96944Medicare UPIN
3004531Medicare ID - Type Unspecified