Provider Demographics
NPI:1265616809
Name:ROBERTS, MARYNA NIKOLAYEVNA (MD)
Entity type:Individual
Prefix:
First Name:MARYNA
Middle Name:NIKOLAYEVNA
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 1:13607 PINE VILLA LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1617
Mailing Address - Country:US
Mailing Address - Phone:239-424-3123
Mailing Address - Fax:239-424-4041
Practice Address - Street 1:1400 COLONIAL BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1055
Practice Address - Country:US
Practice Address - Phone:239-938-9184
Practice Address - Fax:239-313-4687
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME106791207Q00000X
OK26076207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine