Provider Demographics
NPI:1598091068
Name:SCOTT ROBERTSON MD INC
Entity Type:Organization
Organization Name:SCOTT ROBERTSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-489-2205
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-0009
Mailing Address - Country:US
Mailing Address - Phone:805-489-2205
Mailing Address - Fax:805-489-2206
Practice Address - Street 1:901 OAK PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3408
Practice Address - Country:US
Practice Address - Phone:805-489-2205
Practice Address - Fax:805-489-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLP00339667OtherDPH CLINICAL LABORATORY REGISTRATION NUMBER
CAC3228143OtherCA DEPT OF CORPORATIONS NUMBER
CA05D2006808OtherCLIA WAIVER
CA05D2006808OtherCLIA WAIVER