Basic Information
| Provider Information | |||||||||
| NPI: | 1629395405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 TRADEPARK DR | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066792773 | ||||||||
| FaxNumber: | 6066794626 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 TRADEPARK DR | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066792773 | ||||||||
| FaxNumber: | 6066794626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | POD001206 | GA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 00439 | KY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.