Provider Demographics
NPI:1295830875
Name:ROBERTSON, ANDREW L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:ROBERTSON
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 1:115 N HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-2491
Mailing Address - Country:US
Mailing Address - Phone:336-786-5851
Mailing Address - Fax:
Practice Address - Street 1:423 S. SOUTH STREET
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030
Practice Address - Country:US
Practice Address - Phone:336-789-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42152208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33340800Medicaid
H20050Medicare UPIN