Provider Demographics
NPI:1467869354
Name:ROBERTSON, JAY S (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:S
Last Name:ROBERTSON
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 1:584 N SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2862
Mailing Address - Country:US
Mailing Address - Phone:916-250-2596
Mailing Address - Fax:916-550-5025
Practice Address - Street 1:584 N SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2862
Practice Address - Country:US
Practice Address - Phone:916-250-2596
Practice Address - Fax:916-550-5025
Is Sole Proprietor?:No
Enumeration Date:2014-07-13
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17332208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery