Provider Demographics
NPI:1891804092
Name:ROBERTSON, DIRK BRISCOE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIRK
Middle Name:BRISCOE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11 RIVERLY PL NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2500
Mailing Address - Country:US
Mailing Address - Phone:404-351-2922
Mailing Address - Fax:
Practice Address - Street 1:3193 HOWELL MILL RD NW
Practice Address - Street 2:PACES PAVILION SUITE 220
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2119
Practice Address - Country:US
Practice Address - Phone:404-350-5777
Practice Address - Fax:404-350-5755
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025658207N00000X, 207NS0135X, 207ND0900X, 207ND0101X, 208200000X, 208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD46218Medicare UPIN