Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH 5772 | FL |
NPI | 1326167370 |
---|---|
Provider Name | Dr. John Wesley Roberts |
First Address | Palm Bay, FL 32905-4637 |
Second Address | Palm Bay, FL 32905-4637 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
22202 | BLUE CROSS BLUE SHEILD NU (01) | FL |