Provider Demographics
NPI:1053360370
Name:ROBERTS, DALE M (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 ABRAHAM FLEXNER WAY
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3841
Mailing Address - Country:US
Mailing Address - Phone:502-581-9223
Mailing Address - Fax:502-581-9225
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 1105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3841
Practice Address - Country:US
Practice Address - Phone:502-581-9223
Practice Address - Fax:502-581-9225
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22615208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100009950Medicaid
000000043697OtherANTHEM BCBS
KY64226152Medicaid
KY64226152Medicaid
IN100009950Medicaid
A01359Medicare UPIN