Provider Demographics
NPI:1699338640
Name:ROBERTS, MARK T (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2024-05-13
Deactivation Date:2019-12-04
Deactivation Code:
Reactivation Date:2020-04-03
Provider Licenses
StateLicense IDTaxonomies
FL39679390200000X
MI43015093782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology