Provider Demographics
NPI:1972509107
Name:ROBERTS, STANLEY K (DO)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:K
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 1:6914 NOTTINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-9705
Mailing Address - Country:US
Mailing Address - Phone:563-940-8488
Mailing Address - Fax:
Practice Address - Street 1:6914 NOTTINGHAM LN
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-9705
Practice Address - Country:US
Practice Address - Phone:563-940-8488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01934207Q00000X
CO54416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071097Medicaid
IA0152OtherJOHN DEERE HEALTH PLAN
40207OtherWELLMARK BC/BS
034794OtherHEALTH ALLIANCE
4796890009OtherDMERC
19886OtherIOWA HEALTH SOLUTIONS
IA4033811Medicaid
IA4033811Medicaid
4796890009OtherDMERC
IL036071097Medicaid