Basic Information
Provider Information | |||||||||
NPI: | 1821198789 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBLES | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2015 SPRING RD STE 300 | ||||||||
Address2: |   | ||||||||
City: | OAK BROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 605233944 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307252700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 95 GLASTONBURY BLVD STE 202 | ||||||||
Address2: |   | ||||||||
City: | GLASTONBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 060334456 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606528400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 02/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 037949 | CT | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 010037949 | 01 | CT | 01 ANTHEM | OTHER | 001379496 | 05 | CT |   | MEDICAID | 796086 | 01 | CT | CONNECTICARE | OTHER |