Provider Demographics
NPI:1578501573
Name:ROBERTSON, DANIEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
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 1:330 BARCLAY AVE NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2556
Mailing Address - Country:US
Mailing Address - Phone:616-458-1722
Mailing Address - Fax:616-458-0061
Practice Address - Street 1:330 BARCLAY AVE NE
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2556
Practice Address - Country:US
Practice Address - Phone:616-458-1722
Practice Address - Fax:616-458-0061
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDR0873612086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4868466Medicaid
ALP00203119OtherRAILROAD MEDICARE
H80609Medicare UPIN