Provider Demographics
NPI:1952305989
Name:ROBERTO, PAUL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:ROBERTO
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 1:6055 HARBOUR PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2160
Mailing Address - Country:US
Mailing Address - Phone:804-639-7777
Mailing Address - Fax:804-823-2720
Practice Address - Street 1:6055 HARBOUR PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2160
Practice Address - Country:US
Practice Address - Phone:804-639-7777
Practice Address - Fax:804-823-2720
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057462208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7502206Medicaid
VA7502206Medicaid
VA340000606Medicare ID - Type Unspecified
VAC00523Medicare PIN