Provider Demographics
NPI:1801359559
Name:ROBERTS, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:WAYNE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:18071 BISCAYNE BLVD APT 1003
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-5230
Mailing Address - Country:US
Mailing Address - Phone:704-609-5454
Mailing Address - Fax:
Practice Address - Street 1:AVENTURA HOSPITAL & MEDICAL CENTER
Practice Address - Street 2:20900 BISCAYNE BLVD
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33138
Practice Address - Country:US
Practice Address - Phone:305-682-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME153623207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program