Provider Demographics
NPI:1972691368
Name:ROBERTS, MICHAEL PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1001 COLLEGE BLVD W STE D
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1049
Mailing Address - Country:US
Mailing Address - Phone:850-389-8333
Mailing Address - Fax:850-279-6031
Practice Address - Street 1:1001 COLLEGE BLVD W STE D
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1049
Practice Address - Country:US
Practice Address - Phone:850-389-8333
Practice Address - Fax:850-279-6031
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN9115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAM535Medicare PIN
FLAM536AMedicare PIN