Provider Demographics
NPI:1528130929
Name:ROBERTS, WILLARD RAY III
Entity type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:RAY
Last Name:ROBERTS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MORICHES ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1315
Mailing Address - Country:US
Mailing Address - Phone:631-395-4436
Mailing Address - Fax:631-395-4486
Practice Address - Street 1:100 MORICHES ISLAND RD
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1315
Practice Address - Country:US
Practice Address - Phone:631-395-4436
Practice Address - Fax:631-395-4486
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other