Provider Demographics
NPI:1134154511
Name:ROBERTSON, CARROLL BRACEY III (MD)
Entity type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:BRACEY
Last Name:ROBERTSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:902B ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5565
Mailing Address - Country:US
Mailing Address - Phone:252-384-0154
Mailing Address - Fax:252-335-2731
Practice Address - Street 1:902B ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5565
Practice Address - Country:US
Practice Address - Phone:252-384-0154
Practice Address - Fax:252-335-2731
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8972152Medicaid
NC2193979KMedicare PIN
NC8972152Medicaid