Provider Demographics
NPI:1184368979
Name:ROBERTSON, ALEX C (MD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:C
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 1:200 W ESPLANADE AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2475
Mailing Address - Country:US
Mailing Address - Phone:504-464-2940
Mailing Address - Fax:504-464-2941
Practice Address - Street 1:200 W ESPLANADE AVE STE 412
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2475
Practice Address - Country:US
Practice Address - Phone:504-464-2940
Practice Address - Fax:504-464-2941
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343424208D00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program