Provider Demographics
NPI:1275522047
Name:ROBERTS, KENNETH B (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
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 1:15 YORK ST
Mailing Address - Street 2:HUNTER BUILDING, 1ST FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3221
Mailing Address - Country:US
Mailing Address - Phone:203-688-1861
Mailing Address - Fax:203-785-4622
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:HUNTER BUILDING, 1ST FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-688-1861
Practice Address - Fax:203-785-4622
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0322102085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001322106Medicaid
F32504Medicare UPIN
CT001322106Medicaid