Provider Demographics
NPI:1174528848
Name:ROBERTS, EDWARD BROOKE (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:BROOKE
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12930 EAST FWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-5710
Mailing Address - Country:US
Mailing Address - Phone:713-453-6909
Mailing Address - Fax:713-453-7627
Practice Address - Street 1:12930 EAST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-5710
Practice Address - Country:US
Practice Address - Phone:713-453-6909
Practice Address - Fax:713-453-7627
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8969174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88772SOtherBLUE CROSS
TX042245302Medicaid
200040017OtherMEDICARE RAILROAD
TX042245302Medicaid
200040017OtherMEDICARE RAILROAD