Healthcare Provider Details

I. General information

NPI: 1962441915
Provider Name (Legal Business Name): JOHN R ROBERTS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 CRAWFORDSVILLE SQUARE DR
CRAWFORDSVILLE IN
47933-3800
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-362-5789
  • Fax: 765-362-2453
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036855
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: