Healthcare Provider Details

I. General information

NPI: 1942526165
Provider Name (Legal Business Name): NATHAN ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVENUE, SUITE 112
LANSDOWNE VA
20176-8470
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403 SUITE 112
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-724-1195
  • Fax: 703-724-4495
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101259989
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: