Provider Demographics
NPI:1972584381
Name:ROBERTS, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-240-2205
Mailing Address - Fax:320-229-5174
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-240-2205
Practice Address - Fax:320-229-5174
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38900207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
31T17ROOtherBLUE CROSS BLUE SHIELD
COMPOtherMMSI
1033448OtherPREFERRED ONE
2900214OtherMEDICA HEALTH PLANS
COMPOtherCHAMPUS
596608OtherU CARE
2114016OtherFIRST HEALTH PLAN
311325600OtherMEDICAL ASSISTANCE
596608OtherARAZ GROUP AMERICAS PPO
COMPOtherONE HEALTH PLAN GREAT WES
491R2ROOtherBLUE CROSS BLUE SHIELD
HP27097OtherHEALTH PARTNERS
31T17ROOtherBLUE CROSS BLUE SHIELD
2114016OtherFIRST HEALTH PLAN