Provider Demographics
NPI:1578528683
Name:ROBERTSON, DONALD WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WAYNE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828S MCCALL RD 21
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-9517
Mailing Address - Country:US
Mailing Address - Phone:941-474-8154
Mailing Address - Fax:941-473-3583
Practice Address - Street 1:2828 S MCCALL RD
Practice Address - Street 2:STE 21
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-7791
Practice Address - Country:US
Practice Address - Phone:941-474-8154
Practice Address - Fax:941-473-3583
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80126OtherFL BC
FL80126Medicare ID - Type Unspecified
FL80126TMedicare PIN
E54594Medicare UPIN