1316993520 NPI number — STANLEY DWAYNE ROBERTS MD

Table of content: (NPI 1285973487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316993520 NPI number — STANLEY DWAYNE ROBERTS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
STANLEY
Provider Middle Name:
DWAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1316993520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANISH FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84660-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-898-7136
Provider Business Mailing Address Fax Number:
616-975-9824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 N MAIN ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84653-5698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-477-9007
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2006

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: 207PE0004X , with the licence number:  276489 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: 276489-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 107018542102 . This is a "SELECT HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 174069 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 87148 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 52892628603001 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: D1423 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00221212 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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