Healthcare Provider Details

I. General information

NPI: 1275522047
Provider Name (Legal Business Name): KENNETH B ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 YORK ST HUNTER BUILDING, 1ST FLOOR
NEW HAVEN CT
06510-3221
US

IV. Provider business mailing address

15 YORK ST HUNTER BUILDING, 1ST FLOOR
NEW HAVEN CT
06510-3221
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-1861
  • Fax: 203-785-4622
Mailing address:
  • Phone: 203-688-1861
  • Fax: 203-785-4622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number032210
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: