Provider Demographics
NPI:1689760480
Name:ROBERTSON, JOHN MARSHALL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARSHALL
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 1:2121 SANTA MONICA BLVD
Mailing Address - Street 2:SAINT JOHNS HEALTH CENTER
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2303
Mailing Address - Country:US
Mailing Address - Phone:310-829-8618
Mailing Address - Fax:310-829-8607
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-829-8618
Practice Address - Fax:310-829-8607
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38174208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAJR-G38174OtherMEDICARE IDENTIFICATION NUMBER
CAJR-G38174OtherMEDICARE IDENTIFICATION NUMBER
SG38174CMedicare ID - Type Unspecified