Provider Demographics
NPI:1447369665
Name:GAVIN J. ROBERTS, MD
Entity type:Organization
Organization Name:GAVIN J. ROBERTS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-817-1333
Mailing Address - Street 1:PO BOX 68952
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0952
Mailing Address - Country:US
Mailing Address - Phone:317-802-6310
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:201 PENNSYLVANIA PKWY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2301
Practice Address - Country:US
Practice Address - Phone:317-817-1333
Practice Address - Fax:317-817-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN216780Medicare PIN