Provider Demographics
NPI:1992792485
Name:ROBERTS, RICHARD GUY (MD)
Entity type:Individual
Prefix:PROF
First Name:RICHARD
Middle Name:GUY
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 1:777 S MILLS ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1849
Mailing Address - Country:US
Mailing Address - Phone:608-263-3598
Mailing Address - Fax:608-263-5813
Practice Address - Street 1:21 S VINE ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9179
Practice Address - Country:US
Practice Address - Phone:608-424-3384
Practice Address - Fax:608-424-6353
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30531300Medicaid
WI25691OtherLICENSE
B56090Medicare UPIN
WI019C15875Medicare ID - Type Unspecified