Basic Information
| Provider Information | |||||||||
| NPI: | 1114933272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | ELLIOT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | SLOAN BLDG, 5TH FLOOR | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616944447 | ||||||||
| FaxNumber: | 3616944179 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 S ALAMEDA ST | ||||||||
| Address2: | SLOAN BLDG | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616944447 | ||||||||
| FaxNumber: | 3616944179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | N9629 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 283500101 | 05 | TX | MEDICAID | 02785142 | 05 | NY | MEDICAID |