Provider Demographics
NPI:1982825261
Name:ROBERTS, MARK D (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
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 1:5022 CAMPBELL BLVD.
Mailing Address - Street 2:SUITE D
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4931
Mailing Address - Country:US
Mailing Address - Phone:410-931-2096
Mailing Address - Fax:410-931-2106
Practice Address - Street 1:5022 CAMPBELL BLVD.
Practice Address - Street 2:SUITE D
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4931
Practice Address - Country:US
Practice Address - Phone:410-931-2096
Practice Address - Fax:410-931-2106
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSO1228111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5470-0001OtherCFBC
689447OtherUHC
MD20BRMDOtherBCBS
689447OtherUHC
MDKX84Medicare ID - Type UnspecifiedMEDICARE