Provider Demographics
NPI:1508421629
Name:ROBERTSON, KEVIN JOSUE (MD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSUE
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 1:4041 CHOUTEAU AVE APT 126
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1739
Mailing Address - Country:US
Mailing Address - Phone:305-335-0280
Mailing Address - Fax:
Practice Address - Street 1:1201 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-257-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2024-04-22
Deactivation Date:2019-12-23
Deactivation Code:
Reactivation Date:2020-01-11
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2023050232207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program