Provider Demographics
NPI:1134170079
Name:ROBERTS, DONNA M (MD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:550 S JACKSON ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-562-6503
Practice Address - Fax:502-562-6504
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64223514Medicaid
IN200037840Medicaid
KY0048453Medicare PIN
KY01174008Medicare PIN
IN200037840Medicaid
KYC65261Medicare UPIN
KY0523923Medicare PIN
KY0601214Medicare PIN
KY1271213Medicare PIN
KY0766105Medicare PIN
KY0048465Medicare PIN