Provider Demographics
NPI:1932118965
Name:ROBERTS, DAVID F (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:F
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:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-255-4300
Mailing Address - Fax:228-255-3626
Practice Address - Street 1:4300 LEISURE TIME DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3241
Practice Address - Country:US
Practice Address - Phone:228-255-4300
Practice Address - Fax:228-255-3626
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015329Medicaid
MS09015329Medicaid
MS080003511Medicare ID - Type Unspecified
MS302I085000Medicare PIN