Provider Demographics
NPI:1720010556
Name:ROBERTS, CRAIG M (DPM)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5301 BALBOA BLVD
Mailing Address - Street 2:L3
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2702
Mailing Address - Country:US
Mailing Address - Phone:323-587-3011
Mailing Address - Fax:323-587-0309
Practice Address - Street 1:2678 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4708
Practice Address - Country:US
Practice Address - Phone:323-587-3011
Practice Address - Fax:323-587-0309
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3803213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E38032Medicaid
CAU26016Medicare UPIN
CAE3803CMedicare PIN