Provider Demographics
NPI:1528019536
Name:ROBERTSON, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
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:PO BOX 54130
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0130
Mailing Address - Country:US
Mailing Address - Phone:951-687-3400
Mailing Address - Fax:951-687-7630
Practice Address - Street 1:3660 PARK SIERRA DR
Practice Address - Street 2:SUITE 208
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3071
Practice Address - Country:US
Practice Address - Phone:951-687-2800
Practice Address - Fax:951-687-7290
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54428207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G544280Medicaid
CAA52720Medicare UPIN
CA00G544283Medicare PIN