Provider Demographics
NPI:1164730917
Name:ROBINSON, JED (DO)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:
Last Name:ROBINSON
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 1:232 BOLLWEEVIL BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2106 LOOP RD STE B
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3343
Practice Address - Country:US
Practice Address - Phone:318-435-3771
Practice Address - Fax:318-435-7233
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.056367208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA9YJC5OtherMEDICARE
LADO.000376OtherLICENSE
LA12666819OtherCAQH
LA2363247Medicaid