Provider Demographics
NPI:1871595389
Name:ROBERTS, ROGER JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:ROBERTS
Suffix:JR
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-0129
Mailing Address - Country:US
Mailing Address - Phone:317-468-6270
Mailing Address - Fax:317-468-6268
Practice Address - Street 1:300 E BOYD AVE STE 250
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2845
Practice Address - Country:US
Practice Address - Phone:317-467-4500
Practice Address - Fax:317-477-6321
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040512A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200002460Medicaid
IN200311740EOtherMEDICAID GROUP #
IN370018016OtherMEDICARE RAILROAD #
IN4561963OtherAETNA PIN #
IN000000112502OtherANTHEM PIN #
INF79409Medicare UPIN
IN200311740EOtherMEDICAID GROUP #