Provider Demographics
NPI:1538297593
Name:ROBERTSON, DONALD CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:CHARLES
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 CURTIS DR
Mailing Address - Street 2:#200
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1001
Mailing Address - Country:US
Mailing Address - Phone:662-423-6014
Mailing Address - Fax:662-423-2972
Practice Address - Street 1:1771 CURTIS DR
Practice Address - Street 2:#200
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1001
Practice Address - Country:US
Practice Address - Phone:662-423-6014
Practice Address - Fax:662-423-2972
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007005536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I414914Medicare PIN