Provider Demographics
NPI:1871507913
Name:ROBERTS, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 E HIGHWAY 76
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6037
Mailing Address - Country:US
Mailing Address - Phone:843-431-2720
Mailing Address - Fax:843-431-2726
Practice Address - Street 1:2845 E HIGHWAY 76
Practice Address - Street 2:SUITE 4
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6037
Practice Address - Country:US
Practice Address - Phone:843-431-2720
Practice Address - Fax:843-431-2726
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC28818208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5462OtherMEDICAID GROUP
SC288183Medicaid
SCRHC538Medicaid
SCGP0861Medicaid
SCAA14839493Medicare PIN
SCGP0861Medicaid