Provider Demographics
NPI:1629502968
Name:ROBERTSON, EARL (CP, LPO)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:CP, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 N WHITE STATION RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4422
Mailing Address - Country:US
Mailing Address - Phone:901-763-6999
Mailing Address - Fax:901-682-9062
Practice Address - Street 1:722 N WHITE STATION RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4422
Practice Address - Country:US
Practice Address - Phone:901-763-6999
Practice Address - Fax:901-682-9062
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLO 58222Z00000X
TNLP 49224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP 1357OtherABC