Provider Demographics
NPI:1932281011
Name:ROBERTSON, GREGORY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
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 1:20311 SW ACACIA ST
Mailing Address - Street 2:STE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1733
Mailing Address - Country:US
Mailing Address - Phone:949-250-4244
Mailing Address - Fax:
Practice Address - Street 1:20311 SW ACACIA ST
Practice Address - Street 2:STE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1733
Practice Address - Country:US
Practice Address - Phone:949-250-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50555207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51727Medicare UPIN
CAG50555Medicare ID - Type Unspecified