Provider Demographics
NPI:1083688261
Name:ISRAEL, ROBERT N (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:N
Last Name:ISRAEL
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 1:124 SEYMOUR AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3558
Mailing Address - Country:US
Mailing Address - Phone:517-782-5700
Mailing Address - Fax:517-782-3141
Practice Address - Street 1:124 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3558
Practice Address - Country:US
Practice Address - Phone:517-782-5700
Practice Address - Fax:517-782-3141
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRI4301052400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2602310Medicaid
MID93506Medicare UPIN
MI2602310Medicaid