Provider Demographics
NPI:1245624881
Name:ROBERTS, EDWIN JOHN RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:JOHN RAYMOND
Last Name:ROBERTS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 KENTSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4610
Mailing Address - Country:US
Mailing Address - Phone:646-696-8396
Mailing Address - Fax:
Practice Address - Street 1:704 GENERATION PT STE 201
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5918
Practice Address - Country:US
Practice Address - Phone:888-644-1448
Practice Address - Fax:407-343-1710
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJL155ZOtherFL MEDICARE