Provider Demographics
NPI:1043205305
Name:ULSETH, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ULSETH
Suffix:
Gender:M
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:PO BOX 1925
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-1925
Mailing Address - Country:US
Mailing Address - Phone:352-553-4075
Mailing Address - Fax:888-770-3208
Practice Address - Street 1:305 S LINE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4605
Practice Address - Country:US
Practice Address - Phone:352-344-4791
Practice Address - Fax:352-344-3822
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56394174400000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08559OtherBLUE SHIELD PROV #
FL08559OtherBLUE SHIELD PROV #
FLP00071055Medicare PIN
FL08559YMedicare PIN