Provider Demographics
NPI:1417749425
Name:ROBERTS, KEVIN GLENN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GLENN
Last Name:ROBERTS
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 1:1611 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-3039
Mailing Address - Country:US
Mailing Address - Phone:940-368-6521
Mailing Address - Fax:
Practice Address - Street 1:1111 W 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-1886
Practice Address - Country:US
Practice Address - Phone:940-368-6521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program