Provider Demographics
NPI:1770586877
Name:ROBERTS, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
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 1:3620 N 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2344
Mailing Address - Country:US
Mailing Address - Phone:954-964-8480
Mailing Address - Fax:754-400-8543
Practice Address - Street 1:3620 N 55TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-2344
Practice Address - Country:US
Practice Address - Phone:954-964-8480
Practice Address - Fax:754-400-8543
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2021-03-30
Deactivation Date:2016-06-13
Deactivation Code:
Reactivation Date:2016-08-03
Provider Licenses
StateLicense IDTaxonomies
FLME553752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09847OtherBLUE CROSS BLUE SHIELD
FL064827200Medicaid
FL064827200Medicaid
FL064827200Medicaid