Provider Demographics
NPI:1396709515
Name:ROBERTS, ALFRED MACK (MD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:MACK
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5615 HIGH ST W
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3758
Mailing Address - Country:US
Mailing Address - Phone:757-484-5002
Mailing Address - Fax:757-483-9506
Practice Address - Street 1:5615 HIGH ST W
Practice Address - Street 2:SUITE A
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3758
Practice Address - Country:US
Practice Address - Phone:757-484-5002
Practice Address - Fax:757-483-9506
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101030378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5624495Medicaid
VA5624495Medicaid
VA006353M44Medicare PIN
VA010057199Medicare PIN