1245624881 NPI number — DR. EDWIN JOHN RAYMOND ROBERTS M.D.

Table of content: DR. EDWIN JOHN RAYMOND ROBERTS M.D. (NPI 1245624881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245624881 NPI number — DR. EDWIN JOHN RAYMOND ROBERTS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
EDWIN
Provider Middle Name:
JOHN RAYMOND
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1245624881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3412 KENTSHIRE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCOEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34761-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-696-8396
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
704 GENERATION PT STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34744-5918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-644-1448
Provider Business Practice Location Address Fax Number:
407-343-1710
Provider Enumeration Date:
03/21/2015

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:  ME135755 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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