Provider Demographics
NPI:1811072382
Name:ROBERTS, REBECCA JEAN (DO)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 BAHIA VISTA ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2634
Mailing Address - Country:US
Mailing Address - Phone:941-365-6273
Mailing Address - Fax:941-365-4269
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:SUITE 310
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2634
Practice Address - Country:US
Practice Address - Phone:941-365-6273
Practice Address - Fax:941-365-4269
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S5641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C34536Medicare UPIN
80157AMedicare ID - Type Unspecified