Provider Demographics
NPI:1295904993
Name:ROBERTS, JOMAR
Entity type:Individual
Prefix:
First Name:JOMAR
Middle Name:
Last Name:ROBERTS
Suffix:
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-637-1779
Mailing Address - Fax:704-637-1121
Practice Address - Street 1:612 MOCKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2732
Practice Address - Country:US
Practice Address - Phone:704-637-1779
Practice Address - Fax:704-637-1121
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC328212084N0400X
NC2017-025812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1-07246-0Medicaid
LA1-07246-0Medicaid