Provider Demographics
NPI:1336137892
Name:ROBERTSON, ROBERT OSCAR (DO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:OSCAR
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:300 W WASHINGTON AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2180
Mailing Address - Country:US
Mailing Address - Phone:517-783-4664
Mailing Address - Fax:517-783-4698
Practice Address - Street 1:300 W WASHINGTON AVE
Practice Address - Street 2:STE 150
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2180
Practice Address - Country:US
Practice Address - Phone:517-783-4664
Practice Address - Fax:517-783-4698
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P62172OtherAETNA
MI1744106Medicaid
MI700C86358OtherBCBS
MI700C86358OtherBCBS
P62172OtherAETNA