Healthcare Provider Details

I. General information

NPI: 1396709515
Provider Name (Legal Business Name): ALFRED MACK ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5615 HIGH ST W SUITE A
PORTSMOUTH VA
23703-3758
US

IV. Provider business mailing address

5615 HIGH ST W SUITE A
PORTSMOUTH VA
23703-3758
US

V. Phone/Fax

Practice location:
  • Phone: 757-484-5002
  • Fax: 757-483-9506
Mailing address:
  • Phone: 757-484-5002
  • Fax: 757-483-9506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101030378
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: