Healthcare Provider Details

I. General information

NPI: 1235112988
Provider Name (Legal Business Name): BRIAN M. ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 MADONNA RD SUITE B
SAN LUIS OBISPO CA
93405-5432
US

IV. Provider business mailing address

283 MADONNA RD SUITE B
SAN LUIS OBISPO CA
93405-5432
US

V. Phone/Fax

Practice location:
  • Phone: 805-549-8880
  • Fax: 805-783-2009
Mailing address:
  • Phone: 805-549-8880
  • Fax: 805-783-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG45388
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: