Basic Information
| Provider Information | |||||||||
| NPI: | 1104357946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | PAUL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 403458 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331401458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052551127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 W 68TH ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330161801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053642107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS16413 | VA | N | Allopathic & Osteopathic Physicians | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RI0200X | OS16413 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.