1073953238 NPI number — AUDREY JEAN ROBERTS MD

Table of content: AUDREY JEAN ROBERTS MD (NPI 1073953238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073953238 NPI number — AUDREY JEAN ROBERTS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
AUDREY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUDWIG
Provider Other First Name:
AUDREY
Provider Other Middle Name:
ROBERTS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073953238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 N SAN FRANCISCO ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-779-7851
Provider Business Mailing Address Fax Number:
702-671-6883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 N SAN FRANCISCO ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-3260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-779-7851
Provider Business Practice Location Address Fax Number:
928-213-9990
Provider Enumeration Date:
07/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  10180297-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 20203 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 65391 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)