Provider Demographics
NPI:1699709592
Name:ROBERTS, GREGORY L (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
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 1:219 GRANT UTELY AVE NW
Mailing Address - Street 2:PO BOX 67
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 GRANT UTELY AVE NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633
Practice Address - Country:US
Practice Address - Phone:218-335-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30341207Q00000X
MN36046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO080060522OtherRAIL ROAD MEDICARE
CO01303411Medicaid
MN080021653Medicare PIN
CO080060522OtherRAIL ROAD MEDICARE
COE67588Medicare UPIN