Provider Demographics
NPI:1154404952
Name:ROBERTS, WILLIAM OLIVER (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:OLIVER
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:651-772-3461
Mailing Address - Fax:
Practice Address - Street 1:UFP PHALEN VILLAGE CLINIC
Practice Address - Street 2:1414 MARYLAND AVENUE EAST
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24845207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-12528OtherMEDICA PRIMARY
MN102775OtherUCARE
MN0506013OtherPREFERRED ONE
MN01-12528OtherMEDICA CHOICE
MN681282100Medicaid
MN1780296OtherARAZ
MN061L6ROOtherBLUE CROSS BLUE SHIELD
MNHP17043OtherHEALTH PARTNERS
IA1519736Medicaid
A95514Medicare UPIN
MN1780296OtherARAZ