Healthcare Provider Details

I. General information

NPI: 1770620403
Provider Name (Legal Business Name): DAVID F. ROBERTS, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 GEX RD
DIAMONDHEAD MS
39525-3208
US

IV. Provider business mailing address

PO BOX 6130
DIAMONDHEAD MS
39525-6002
US

V. Phone/Fax

Practice location:
  • Phone: 228-255-4300
  • Fax: 228-255-3626
Mailing address:
  • Phone: 228-255-4300
  • Fax: 228-255-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11771
License Number StateMS

VIII. Authorized Official

Name: MRS. CHELE M WALLEY
Title or Position: BILLING MANAGER
Credential:
Phone: 228-255-4300