Healthcare Provider Details

I. General information

NPI: 1730443078
Provider Name (Legal Business Name): RONALD BRENT ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2466 FLOWOOD DR SUITE E
FLOWOOD MS
39232-9019
US

IV. Provider business mailing address

2466 FLOWOOD DR SUITE E
FLOWOOD MS
39232-9019
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-5700
  • Fax: 601-815-5795
Mailing address:
  • Phone: 601-815-5700
  • Fax: 601-815-5795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number860-L
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: