MEDICARE: MARYNA NIKOLAYEVNA ROBERTS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME106791	FL
2	207Q00000X	Family Medicine Physician	26076	OK

General Provider Information

NPI Number	:	1265616809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYNA NIKOLAYEVNA ROBERTS M.D.

Provider Business Mailing Address
First Line	:	13607 PINE VILLA LN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-1617
Country	:	US
Telephone Number	:	239-424-3123
Fax Number	:	239-424-4041

Provider Business Practice Location Address
First Line	:	1400 COLONIAL BLVD
Second Line	:	SUITE 203
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1055
Country	:	US
Telephone Number	:	239-938-9184
Fax Number	:	239-313-4687

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	12/05/2016

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