Provider Demographics
NPI:1003811332
Name:JANSEN, ROBERT DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:JANSEN
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 1:55 WHITCHER ST NE
Mailing Address - Street 2:STE 460
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1171
Mailing Address - Country:US
Mailing Address - Phone:770-427-7389
Mailing Address - Fax:770-427-2845
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:STE 460
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1171
Practice Address - Country:US
Practice Address - Phone:770-427-7389
Practice Address - Fax:770-427-2845
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
GAGA027578207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000332857UMedicaid
GA000332857DMedicaid
GA00332857AMedicaid
GA000332857ACMedicaid
GA000332857PMedicaid
GA000332857QMedicaid
GA000332857VMedicaid
GA000332857EMedicaid
GA000332857HMedicaid
GA000332857HMedicaid