Provider Demographics
NPI:1740276856
Name:ROBINSON, JACK STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:STEPHEN
Last Name:ROBINSON
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 1:204 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77303-1567
Mailing Address - Country:US
Mailing Address - Phone:936-756-3167
Mailing Address - Fax:936-756-3509
Practice Address - Street 1:18059 HIGHWAY 105 W
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-5802
Practice Address - Country:US
Practice Address - Phone:936-582-5620
Practice Address - Fax:936-582-5621
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3800208000000X
CAG32552208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158814701Medicaid
TX158814701Medicaid
TXBR7710191OtherDEA NUMBER
TXA91455Medicare UPIN