Basic Information
| Provider Information | |||||||||
| NPI: | 1700231909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1329 SW 16TH ST | ||||||||
| Address2: | PO BOX 100186 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522655911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1329 SW 16TH ST | ||||||||
| Address2: | SUITE 5270 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522655911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2016 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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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 | 207P00000X | ME139032 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103412500 | 05 | FL | MEDICAID |