Provider Demographics
NPI:1922094507
Name:ROBERTS, DUDLEY III (MD)
Entity Type:Individual
Prefix:
First Name:DUDLEY
Middle Name:
Last Name:ROBERTS
Suffix:III
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 1:18245 E 10 MILE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5807
Mailing Address - Country:US
Mailing Address - Phone:586-774-8710
Mailing Address - Fax:
Practice Address - Street 1:18245 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5807
Practice Address - Country:US
Practice Address - Phone:586-774-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDR051585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110227501OtherRRMR
MI1105015902OtherBS
MI104715716Medicaid
MI383712316OtherPPOM
MIP115806OtherBCN
MI104715716Medicaid
MI383712316OtherPPOM