Provider Demographics
NPI:1265549265
Name:ROBERTS, ERIC L (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:L
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 1:60 N COUNTRY RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2188
Mailing Address - Country:US
Mailing Address - Phone:631-474-4200
Mailing Address - Fax:631-474-4202
Practice Address - Street 1:60 N COUNTRY RD
Practice Address - Street 2:SUITE 301
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2188
Practice Address - Country:US
Practice Address - Phone:631-474-4200
Practice Address - Fax:631-474-4202
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01575424Medicaid
NY01575424Medicaid