Provider Demographics
NPI:1720066988
Name:ROBERTS, LORAN WILLIS (MD)
Entity Type:Individual
Prefix:
First Name:LORAN
Middle Name:WILLIS
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 1:75 SPRINGFIELD RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-1790
Mailing Address - Country:US
Mailing Address - Phone:413-572-2973
Mailing Address - Fax:413-572-2975
Practice Address - Street 1:75 SPRINGFIELD RD
Practice Address - Street 2:SUITE 3
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-1790
Practice Address - Country:US
Practice Address - Phone:413-572-2973
Practice Address - Fax:413-572-2975
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80758208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
103178000OtherDEPT OF LABOR
1037878OtherUS HEALTHCARE
043414755OtherTAX ID
080758OtherTUFTS AND MEDICARE PREFER
MAJ16048OtherBCBS OF MA
0021661OtherNEIGHBORHOOD HEALTH
15956OtherHEALTH NEW ENGLAND
20254OtherBMC HEALTHNET
MA2874901OtherCIGNA
101273OtherCIGNA
1037878OtherAETNA
MA3137902Medicaid
777730OtherCONNETICARE
J16048OtherBLUECROSS BLUESHIELD
MA80758OtherLICENSE NUMBER
97875OtherKAISER
97875OtherKAISER
020039183Medicare ID - Type UnspecifiedRAILROAD
MA3137902Medicaid
0021661OtherNEIGHBORHOOD HEALTH
MA80758OtherLICENSE NUMBER