=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376519421
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMILLE IVAH ROBERTS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2006
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 KIMEL PARK DR
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-6951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-718-1006
-----------------------------------------------------
Fax | 336-718-1099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 GROVE ST SUITE 304
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605-1270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-890-5500
-----------------------------------------------------
Fax | 508-890-5505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 223309
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------