Provider Demographics
NPI:1194890848
Name:ROBERTS, KENNETH C (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
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 850299
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73085-0299
Mailing Address - Country:US
Mailing Address - Phone:985-966-3757
Mailing Address - Fax:
Practice Address - Street 1:400 VETERANS
Practice Address - Street 2:
Practice Address - City:BILOXY
Practice Address - State:MS
Practice Address - Zip Code:39531
Practice Address - Country:US
Practice Address - Phone:228-523-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021531207R00000X
MS18538207R00000X
OK2974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F83536Medicare UPIN
LASU433Medicare ID - Type Unspecified