Provider Demographics
NPI:1902919111
Name:PICKETT, ROBERTA L (MD)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:L
Last Name:PICKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-683-6370
Mailing Address - Fax:
Practice Address - Street 1:12742 LIMONITE AVENUE
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880
Practice Address - Country:US
Practice Address - Phone:951-739-2710
Practice Address - Fax:951-371-6587
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81828208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABP8553489OtherDEA