Provider Demographics
NPI:1629133400
Name:ROBERSON, GARY ALAN (M D)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALAN
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1855 LAKELAND DR
Mailing Address - Street 2:SUITE P-231
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4913
Mailing Address - Country:US
Mailing Address - Phone:601-906-4479
Mailing Address - Fax:601-366-3256
Practice Address - Street 1:3550 HIGHWAY 468 WEST
Practice Address - Street 2:
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-0157
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8301
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS154742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS008124779Medicaid
MN260002937OtherMEDICARE PTAN
MS260003004Medicare PIN
MN260002937OtherMEDICARE PTAN
MSG67325Medicare UPIN