Provider Demographics
NPI:1881192367
Name:PHELPS, ROBERT MILTON JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MILTON
Last Name:PHELPS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2252 ENCORE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5112
Mailing Address - Country:US
Mailing Address - Phone:937-725-2682
Mailing Address - Fax:
Practice Address - Street 1:2252 ENCORE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-5112
Practice Address - Country:US
Practice Address - Phone:937-725-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0868422Medicaid