Provider Demographics
NPI:1629069612
Name:ROBERTSON, BARRY (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
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:PO BOX 42508
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-0508
Mailing Address - Country:US
Mailing Address - Phone:513-423-6654
Mailing Address - Fax:513-423-7567
Practice Address - Street 1:136 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042
Practice Address - Country:US
Practice Address - Phone:513-423-6654
Practice Address - Fax:513-423-7567
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH40096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0365028Medicaid
OH0365028Medicaid
OHRO0440936Medicare PIN
OH0440935Medicare PIN