Provider Demographics
NPI:1730677881
Name:ROBERTS, MARK A (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 111
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-0111
Mailing Address - Country:US
Mailing Address - Phone:312-961-9391
Mailing Address - Fax:
Practice Address - Street 1:10552 N WATTS SPRINGS PARK RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-8947
Practice Address - Country:US
Practice Address - Phone:312-961-9391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK164022083X0100X
WI311652083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine