Provider Demographics
NPI:1912178849
Name:ROBERTS, TERRY
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:
Last Name:ROBERTS
Suffix:
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 1:5517 CLARKS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30527-2231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5517 CLARKS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:GA
Practice Address - Zip Code:30527-2231
Practice Address - Country:US
Practice Address - Phone:770-983-3755
Practice Address - Fax:770-983-0383
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1218800001Medicare NSC