1679737316 NPI number — DR. TIMOTHY DUANE ROBERTS LICENSED PROFESSIONA

Table of content: DR. TIMOTHY DUANE ROBERTS LICENSED PROFESSIONA (NPI 1679737316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679737316 NPI number — DR. TIMOTHY DUANE ROBERTS LICENSED PROFESSIONA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
TIMOTHY
Provider Middle Name:
DUANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED PROFESSIONA
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:
1679737316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E FRONT STREET
Provider Second Line Business Mailing Address:
SUITE 142
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-533-8008
Provider Business Mailing Address Fax Number:
903-533-8008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 E FRONT STREET
Provider Second Line Business Practice Location Address:
SUITE 142
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-533-8008
Provider Business Practice Location Address Fax Number:
903-533-8008
Provider Enumeration Date:
07/11/2008

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: 101YP2500X , with the licence number:  69790 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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