Provider Demographics
NPI:1417301664
Name:ROBERTSON, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:5275 STATE ROUTE 122 STE 100
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-9617
Mailing Address - Country:US
Mailing Address - Phone:513-424-7291
Mailing Address - Fax:513-424-2289
Practice Address - Street 1:5275 STATE ROUTE 122 STE 100
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-9617
Practice Address - Country:US
Practice Address - Phone:513-424-7291
Practice Address - Fax:513-424-2289
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.136095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty