Provider Demographics
NPI:1457357832
Name:ROBERTSON, JAMES WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WALLACE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5024 N ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9230
Mailing Address - Country:US
Mailing Address - Phone:231-935-0555
Mailing Address - Fax:
Practice Address - Street 1:5024 N ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9230
Practice Address - Country:US
Practice Address - Phone:231-935-0555
Practice Address - Fax:231-935-0562
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065685208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1065685Medicaid
MI1065685Medicaid