Provider Demographics
NPI:1750384681
Name:ROBERTO, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:ROBERTO
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 1:3250 MIDDLE URBANA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-9285
Mailing Address - Country:US
Mailing Address - Phone:937-399-7777
Mailing Address - Fax:937-399-6794
Practice Address - Street 1:3250 MIDDLE URBANA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-9285
Practice Address - Country:US
Practice Address - Phone:937-399-7777
Practice Address - Fax:937-399-6794
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-6604-R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080010552OtherRR MEDICARE
OHOH0032545OtherTRICARE/CHAMPUS
OH000000014201OtherANTHEM
OH0466419Medicaid
OH0101219OtherUNITED HEALTH CARE
OH311202780008OtherCIGNA
OH4013944OtherAETNA
OH0497625Medicare PIN