Provider Demographics
NPI:1689784241
Name:ROBERTS, DONNY
Entity Type:Individual
Prefix:
First Name:DONNY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5256 COUNTY ROAD 3560
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0349
Mailing Address - Country:US
Mailing Address - Phone:580-332-0669
Mailing Address - Fax:
Practice Address - Street 1:2020 ARLINGTON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2822
Practice Address - Country:US
Practice Address - Phone:580-332-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK412OtherLICENSE#