=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346391653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILMER BURTON ROBERTS MD, PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 08/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 LAKE RD STE 200
-----------------------------------------------------
City | LAKE JACKSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77566-4982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-299-0011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 LAKE RD STE 200
-----------------------------------------------------
City | LAKE JACKSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77566-4982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-299-0011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | AJ4147357
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 245650
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | S7326
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------