Provider Demographics
NPI:1619223989
Name:ROBERTS, JAMES GLEN (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:GLEN
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 1:2919 SAND PINE ROAD
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-7835
Mailing Address - Country:US
Mailing Address - Phone:850-267-1014
Mailing Address - Fax:
Practice Address - Street 1:2919 SAND PINE ROAD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-7835
Practice Address - Country:US
Practice Address - Phone:850-267-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD009377207V00000X
FLME88436207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology