Provider Demographics
NPI:1023544749
Name:ROBERTSON, BRIAN TODD (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:TODD
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
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 3395
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47732-3395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IN
Practice Address - Zip Code:47243-9481
Practice Address - Country:US
Practice Address - Phone:812-866-3301
Practice Address - Fax:812-866-3327
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4511207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN412840123OtherMEDICARE
IN300037404Medicaid
KY7100544410Medicaid