Provider Demographics
NPI:1871588699
Name:ROBERTS, GEOFFREY (DO)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3542 S. SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34448
Mailing Address - Country:US
Mailing Address - Phone:352-795-5544
Mailing Address - Fax:
Practice Address - Street 1:3542 S. SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34448
Practice Address - Country:US
Practice Address - Phone:352-503-2078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4752207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82659OtherBCBS
FL047517300Medicaid
FL82659OtherBCBS
FLD60694Medicare UPIN
FL047517300Medicaid