Provider Demographics
NPI:1700105624
Name:ROBERTS, CHARLECINTH (MD)
Entity Type:Individual
Prefix:
First Name:CHARLECINTH
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLECINTH
Other - Middle Name:
Other - Last Name:YENNIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:675 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1273
Mailing Address - Country:US
Mailing Address - Phone:860-714-2913
Mailing Address - Fax:860-714-8988
Practice Address - Street 1:675 TOWER AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1273
Practice Address - Country:US
Practice Address - Phone:860-714-2913
Practice Address - Fax:860-714-8988
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT52104207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT052104OtherSTATE LICENSE