Provider Demographics
NPI:1871591164
Name:ROBERTS, FREDERICK WILLIAM (DO)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:WILLIAM
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 1:3273 DAVISON RD
Mailing Address - Street 2:STE 5
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-4306
Mailing Address - Country:US
Mailing Address - Phone:810-245-7766
Mailing Address - Fax:810-245-6216
Practice Address - Street 1:3273 DAVISON RD
Practice Address - Street 2:STE 5
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4306
Practice Address - Country:US
Practice Address - Phone:810-245-7766
Practice Address - Fax:810-245-6216
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010293207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4115633Medicaid
E82763Medicare UPIN
MI4115633Medicaid