Healthcare Provider Details

I. General information

NPI: 1013997782
Provider Name (Legal Business Name): E. DWAIN ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 W STADIUM BLVD
JEFFERSON CITY MO
65109-6023
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 573-556-7755
  • Fax: 573-761-3599
Mailing address:
  • Phone: 573-556-7755
  • Fax: 573-761-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number114884
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number114884
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number114884
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: