Provider Demographics
NPI:1962441915
Name:ROBERTS, JOHN R JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:ROBERTS
Suffix:JR
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1640 CRAWFORDSVILLE SQUARE DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3800
Practice Address - Country:US
Practice Address - Phone:765-362-5789
Practice Address - Fax:765-362-2453
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100324060Medicaid
INM400075750OtherMEDICARE PROVIDER PTAN
INM400075750OtherMEDICARE PROVIDER PTAN
E06490Medicare UPIN