Healthcare Provider Details

I. General information

NPI: 1699338640
Provider Name (Legal Business Name): MARK T ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date: 12/04/2019
Reactivation Date: 04/03/2020

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-7520
  • Fax:
Mailing address:
  • Phone: 305-585-6000
  • Fax: 305-243-6858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME171744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: