Provider Demographics
NPI:1922180900
Name:ROBERTS, DOUGLAS WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 TULLY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4994
Mailing Address - Country:US
Mailing Address - Phone:209-577-1274
Mailing Address - Fax:209-577-2243
Practice Address - Street 1:1136 TULLY RD STE 1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4994
Practice Address - Country:US
Practice Address - Phone:209-577-1274
Practice Address - Fax:209-577-2243
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122610111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO122610Medicare UPIN