Healthcare Provider Details

I. General information

NPI: 1558304865
Provider Name (Legal Business Name): TIM DAVID ROBARTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3585
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-8777
  • Fax: 321-434-1775
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME121753
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier014541200
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
IdentifierP01739899
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerFL RR MEDICARE
# 3
Identifier020042219
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 4
Identifier014541200
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: