Provider Demographics
NPI:1861481004
Name:ROBERTS, JOHN WOODSON (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WOODSON
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1455 MONTEGO
Mailing Address - Street 2:STE 102
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2990
Mailing Address - Country:US
Mailing Address - Phone:925-935-0627
Mailing Address - Fax:925-937-6967
Practice Address - Street 1:1455 MONTEGO
Practice Address - Street 2:STE 102
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2990
Practice Address - Country:US
Practice Address - Phone:925-935-0627
Practice Address - Fax:925-937-6967
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG35198208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G351980Medicaid
CA00G351980Medicaid
CA00G351980Medicare ID - Type Unspecified