Provider Demographics
NPI:1013997782
Name:ROBERTS, E. DWAIN (MD)
Entity Type:Individual
Prefix:DR
First Name:E.
Middle Name:DWAIN
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 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7755
Mailing Address - Fax:573-761-3599
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7755
Practice Address - Fax:573-761-3599
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1148842085N0904X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209786607Medicaid
MOCC7852OtherRR GROUP
MO300090314OtherRAILROAD MEDICARE
MODB1586OtherGROUP RR
MOP00201659OtherIND. RR
MO209786607Medicaid
MOP00201659OtherIND. RR