Provider Demographics
NPI:1871683979
Name:ROBERTS, JASON RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RAY
Last Name:ROBERTS
Suffix:
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 1:8051 S EMERSON AVE
Mailing Address - Street 2:#200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8600
Mailing Address - Country:US
Mailing Address - Phone:317-865-2955
Mailing Address - Fax:
Practice Address - Street 1:8051 S EMERSON AVE
Practice Address - Street 2:#200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8600
Practice Address - Country:US
Practice Address - Phone:317-865-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074928A207RG0100X
SC27169207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201207130Medicaid
KYK094540Medicare PIN