Healthcare Provider Details

I. General information

NPI: 1386663979
Provider Name (Legal Business Name): RONALD EARL ROBERTS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 BEVINS LN
GEORGETOWN KY
40324-6178
US

IV. Provider business mailing address

2195 HARRODSBURG RD STE 125
LEXINGTON KY
40504-3504
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9333
  • Fax:
Mailing address:
  • Phone: 859-323-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32142
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32142
License Number StateKY

VII. Legacy identifiers

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

# 1
IdentifierCB5773
Identifier TypeOTHER
Identifier StateKY
Identifier IssuerRR MEDICARE GROUP
# 2
Identifier64321425
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer
# 3
Identifier4000501
Identifier TypeOTHER
Identifier StateKY
Identifier IssuerMEDICARE LAB GROUP
# 4
Identifier110244643
Identifier TypeOTHER
Identifier StateKY
Identifier IssuerRR MEDICARE PIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: