Healthcare Provider Details

I. General information

NPI: 1619057064
Provider Name (Legal Business Name): JUSTIN W. ROBERTS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WEST PINE STREET
FARMINGTON MO
63640
US

IV. Provider business mailing address

501 WEST PINE STREET
FARMINGTON MO
63640-1439
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-8888
  • Fax: 866-291-5617
Mailing address:
  • Phone: 573-756-8888
  • Fax: 573-701-9547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2004027799
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: