Basic Information
| Provider Information | |||||||||
| NPI: | 1093828378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWK | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1072 XRAY DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046711094 | ||||||||
| FaxNumber: | 7046711095 | ||||||||
| Practice Location | |||||||||
| Address1: | 649 N NEW HOPE RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048664005 | ||||||||
| FaxNumber: | 7048660450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 201802113 | NC | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | NN4199A | 01 | NC | NC MEDICARE | OTHER | 000011761 | 01 | BLUE CROSS | OTHER | 2018-02113 | 01 | NC | NC MEDICAL LICENSE | OTHER | 260015882003 | 01 | EBMS | OTHER |