Provider Demographics
NPI:1578531414
Name:ROBERSON, VIRGIL ODELL III (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:ODELL
Last Name:ROBERSON
Suffix:III
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 4581
Mailing Address - Street 2:
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-4581
Mailing Address - Country:US
Mailing Address - Phone:866-434-2745
Mailing Address - Fax:336-434-6478
Practice Address - Street 1:1092 TOWN & COUNTRY DR
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697
Practice Address - Country:US
Practice Address - Phone:866-434-2745
Practice Address - Fax:336-434-6478
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17423207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89128JFMedicaid
NCC86165Medicare UPIN
NC89128JFMedicaid