Provider Demographics
NPI:1346466323
Name:ROBERTS, BRENDA DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:DIANE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:DIANE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:18 NW 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-4175
Mailing Address - Country:US
Mailing Address - Phone:360-952-4457
Mailing Address - Fax:360-828-7409
Practice Address - Street 1:18 NW 20TH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4175
Practice Address - Country:US
Practice Address - Phone:360-952-4457
Practice Address - Fax:360-828-7409
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 21507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01369929OtherRR MEDICARE (PH&S)
OR276859Medicaid
ORR174895Medicare PIN
ORP01369929OtherRR MEDICARE (PH&S)
ORR175070Medicare PIN
ORR177789Medicare PIN