Healthcare Provider Details

I. General information

NPI: 1770761603
Provider Name (Legal Business Name): JEFFREY BENNINGTON ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13540 HULL STREET RD
MIDLOTHIAN VA
23112-2107
US

IV. Provider business mailing address

13540 HULL STREET RD
MIDLOTHIAN VA
23112-2107
US

V. Phone/Fax

Practice location:
  • Phone: 804-739-6142
  • Fax: 804-739-8923
Mailing address:
  • Phone: 804-739-6142
  • Fax: 804-739-8923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101248946
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2007-00785
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: