Provider Demographics
NPI:1508959180
Name:HOLBERT, ROBERT DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:HOLBERT
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 1:2105 OLD SPANISH TRAIL
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553
Mailing Address - Country:US
Mailing Address - Phone:228-497-9444
Mailing Address - Fax:
Practice Address - Street 1:2105 OLD SPANISH TRAIL
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553
Practice Address - Country:US
Practice Address - Phone:228-497-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07213207R00000X
AL00020583207R00000X
FLME0017076207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110227363OtherRAILROAD MEDICARE
MS00120395Medicaid
MS$$$$$$$$$DOtherBLUE CROSS /BLUE SHIELD OF MS
$$$$$$$$$OtherAETNA
MSB30540Medicare UPIN
$$$$$$$$$OtherAETNA