Provider Demographics
NPI:1811153836
Name:MARK W ROBERTS MD INC
Entity type:Organization
Organization Name:MARK W ROBERTS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMA/MEDICAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-983-6400
Mailing Address - Street 1:1580 CREEKSIDE DR
Mailing Address - Street 2:SUITE NUMBER 130
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3886
Mailing Address - Country:US
Mailing Address - Phone:916-983-6400
Mailing Address - Fax:916-983-6011
Practice Address - Street 1:1580 CREEKSIDE DR
Practice Address - Street 2:SUITE NUMBER 130
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3886
Practice Address - Country:US
Practice Address - Phone:916-983-6400
Practice Address - Fax:916-983-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72120305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX80279Medicare UPIN
CAZZZ24440ZMedicare PIN