Provider Demographics
NPI:1487679700
Name:ROBERTSON, MARK STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
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 1:950 29TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3415
Mailing Address - Country:US
Mailing Address - Phone:541-967-0404
Mailing Address - Fax:541-967-6548
Practice Address - Street 1:950 29TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3415
Practice Address - Country:US
Practice Address - Phone:541-967-0404
Practice Address - Fax:541-967-6548
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23994207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286847Medicaid
ORG83850Medicare UPIN
OR286847Medicaid