1104168459 NPI number — DR. JESSIELA VENIS ROBERTS M.D.

Table of content: DR. JESSIELA VENIS ROBERTS M.D. (NPI 1104168459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104168459 NPI number — DR. JESSIELA VENIS ROBERTS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
JESSIELA
Provider Middle Name:
VENIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104168459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 W BRINKLEY LOOP
Provider Second Line Business Mailing Address:
APT. 2
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72364-5033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-325-2103
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 S 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72901-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-785-2431
Provider Business Practice Location Address Fax Number:
479-785-0732
Provider Enumeration Date:
03/25/2013

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: 207Q00000X , with the licence number:  E-9138 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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