Provider Demographics
NPI:1356736268
Name:ROBERTO, EDWARD SAMUEL
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:SAMUEL
Last Name:ROBERTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E APPLE ST
Mailing Address - Street 2:STE 3300
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-8394
Mailing Address - Fax:
Practice Address - Street 1:128 E APPLE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2902
Practice Address - Country:US
Practice Address - Phone:937-208-2004
Practice Address - Fax:937-208-8828
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.129798207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program