Provider Demographics
NPI:1659329233
Name:ROBERTSON, GREGORY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:J
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:877 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3292
Mailing Address - Country:US
Mailing Address - Phone:805-474-8450
Mailing Address - Fax:805-474-8454
Practice Address - Street 1:1100 LAS TABLAS RD
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9704
Practice Address - Country:US
Practice Address - Phone:805-434-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76912207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00169429OtherMEDICARE RAILROAD
CA00A769120Medicaid
CAP00169429OtherMEDICARE RAILROAD
CA00A769120Medicaid