Provider Demographics
NPI:1801972468
Name:ROBERTS, GARY FREY (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:FREY
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:PO BOX 940801
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75094-0801
Mailing Address - Country:US
Mailing Address - Phone:972-223-8221
Mailing Address - Fax:972-223-0733
Practice Address - Street 1:2692 N GALLOWAY AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6360
Practice Address - Country:US
Practice Address - Phone:972-223-8221
Practice Address - Fax:972-223-0733
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H48VOtherBCBS
TX033735401Medicaid
TX080033133OtherRR MEDICARE
TX00H48VMedicare ID - Type Unspecified
TX00H48VOtherBCBS