Provider Demographics
NPI:1821071531
Name:TIMBERLAKE, ROBERTS EDGAR JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTS
Middle Name:EDGAR
Last Name:TIMBERLAKE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 NC HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-8601
Mailing Address - Country:US
Mailing Address - Phone:336-250-2192
Mailing Address - Fax:
Practice Address - Street 1:741 VINEYARDS XING
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27295-2076
Practice Address - Country:US
Practice Address - Phone:336-300-8594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33759208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8983549Medicaid
NC8983549Medicaid