Provider Demographics
NPI:1497492367
Name:ROBERTSON, GARY MAGIC
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MAGIC
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3747
Mailing Address - Country:US
Mailing Address - Phone:301-325-0813
Mailing Address - Fax:
Practice Address - Street 1:3423 5TH ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-5441
Practice Address - Country:US
Practice Address - Phone:202-765-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide