Provider Demographics
NPI:1386612836
Name:ROBERTS, TIMOTHY R (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
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 1:601 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-6903
Mailing Address - Country:US
Mailing Address - Phone:920-622-3257
Mailing Address - Fax:920-787-5433
Practice Address - Street 1:601 GROVE AVE
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-6903
Practice Address - Country:US
Practice Address - Phone:920-622-3257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48464207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34899200Medicaid
WII61511Medicare UPIN
WI34899200Medicaid