Provider Demographics
NPI:1093760191
Name:ROBERTS, SIDNEY CREED (MD)
Entity type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:CREED
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95350
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-9733
Mailing Address - Country:US
Mailing Address - Phone:877-839-9517
Mailing Address - Fax:903-531-2337
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-639-7466
Practice Address - Fax:936-639-7472
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH46532085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110403601Medicaid
TX85R980OtherBCBS OF TEXAS
TX85R980OtherBCBS OF TEXAS
TX85R980Medicare ID - Type Unspecified