Provider Demographics
NPI:1679517411
Name:ROBERTSON, DENZIL G (MD)
Entity Type:Individual
Prefix:DR
First Name:DENZIL
Middle Name:G
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 1:1850 CHADWICK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3404
Mailing Address - Country:US
Mailing Address - Phone:601-376-2022
Mailing Address - Fax:601-376-1816
Practice Address - Street 1:1850 CHADWICK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3404
Practice Address - Country:US
Practice Address - Phone:601-376-2022
Practice Address - Fax:601-376-1816
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117375Medicaid
MS00117375Medicaid
MS110002004Medicare PIN