Provider Demographics
NPI:1700913183
Name:ROBERTS, PHILIP R (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HEWITT DR STE 203
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8834
Mailing Address - Country:US
Mailing Address - Phone:512-785-0108
Mailing Address - Fax:
Practice Address - Street 1:1201 HEWITT DR STE 203
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8834
Practice Address - Country:US
Practice Address - Phone:512-785-0108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6699207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43495300Medicare ID - Type UnspecifiedWI MA#