Provider Demographics
NPI:1912971045
Name:ROBERTS, THOMAS E (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
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 1:15405 LOS GATOS BLVD
Mailing Address - Street 2:104
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2500
Mailing Address - Country:US
Mailing Address - Phone:408-358-3828
Mailing Address - Fax:408-358-2573
Practice Address - Street 1:15405 LOS GATOS BLVD
Practice Address - Street 2:104
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2500
Practice Address - Country:US
Practice Address - Phone:408-358-3828
Practice Address - Fax:408-358-2573
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG038535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-2881543OtherTAX IDENTIFICATION NUMBER
CAA47509Medicare UPIN
CA00G385350Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER