Basic Information
| Provider Information | |||||||||
| NPI: | 1093760191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | CREED | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95350 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760999733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778399517 | ||||||||
| FaxNumber: | 9035312337 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 W FRANK AVE | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366397466 | ||||||||
| FaxNumber: | 9366397472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | H4653 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0203X | H4653 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 110403601 | 05 | TX | MEDICAID | 85R980 | 01 | TX | BCBS OF TEXAS | OTHER |