Provider Demographics
NPI:1831218817
Name:ROBERTS, JACOB EDWARD (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:EDWARD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:7932 GOSHEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-5002
Mailing Address - Country:US
Mailing Address - Phone:248-417-7730
Mailing Address - Fax:
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:MARION PROFESSIONAL BUILDING SUITE 311
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-655-2692
Practice Address - Fax:734-655-4218
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2009-10-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101015635208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0256305894OtherBCBSM INDIV
MI010H233560OtherBCBSM GRP
MI010H233560OtherBCBSM GRP