Provider Demographics
NPI:1881751667
Name:ROBERTS, JONATHAN JERARD (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JERARD
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 1:2240 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2828
Mailing Address - Country:US
Mailing Address - Phone:985-348-6139
Mailing Address - Fax:877-870-5503
Practice Address - Street 1:2240 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2828
Practice Address - Country:US
Practice Address - Phone:985-348-6139
Practice Address - Fax:877-870-5503
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1930628OtherINTERNAL MEDICINE
LA1930628Medicaid
LA021278OtherM.D. LICENSE
721511296OtherEMPLOYER TAX ID
LAF27917Medicare UPIN