Provider Demographics
NPI:1962584896
Name:ROBERTS, JON W (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 99 & O'BANION STREET
Practice Address - Street 2:
Practice Address - City:BIRCH TREE
Practice Address - State:MO
Practice Address - Zip Code:65438
Practice Address - Country:US
Practice Address - Phone:573-292-3214
Practice Address - Fax:573-292-4442
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240287201Medicaid
MO296013268Medicare PIN
MO240287201Medicaid
MO002013230Medicare PIN