Provider Demographics
NPI:1033545868
Name:GRESHAM, ROBERT JACKSON
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JACKSON
Last Name:GRESHAM
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 1:2500 TAMIAMI TRL N
Mailing Address - Street 2:STE 222
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-4470
Mailing Address - Country:US
Mailing Address - Phone:239-649-8001
Mailing Address - Fax:
Practice Address - Street 1:2500 TAMIAMI TRL N
Practice Address - Street 2:STE 222
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4470
Practice Address - Country:US
Practice Address - Phone:239-649-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42334225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist