Provider Demographics
NPI:1871742338
Name:ROBERTS, PHILLIP DAVID (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:DAVID
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1248 KINNEYS LN
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2927
Practice Address - Country:US
Practice Address - Phone:740-356-7290
Practice Address - Fax:740-356-7938
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2958410Medicaid
OH4276531Medicare PIN
OHH299360Medicare PIN