Provider Demographics
NPI:1265416465
Name:ROBERTS, DAVID (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WIDGER RD
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2146
Mailing Address - Country:US
Mailing Address - Phone:781-631-8250
Mailing Address - Fax:781-639-2060
Practice Address - Street 1:1 WIDGER RD
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2146
Practice Address - Country:US
Practice Address - Phone:781-631-8250
Practice Address - Fax:781-639-2060
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65129OtherBCBS
MA0344346Medicaid
MA0344346Medicaid