Provider Demographics
NPI:1336244748
Name:ROBERTS, DAVID G III (MD, LLC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:ROBERTS
Suffix:III
Gender:M
Credentials:MD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10753 FALLS RD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4535
Mailing Address - Country:US
Mailing Address - Phone:410-583-7979
Mailing Address - Fax:410-847-3516
Practice Address - Street 1:10753 FALLS RD
Practice Address - Street 2:SUITE 255
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4535
Practice Address - Country:US
Practice Address - Phone:410-583-7979
Practice Address - Fax:410-847-3516
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034988207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD76332Medicare UPIN
MD5400Medicare ID - Type Unspecified