Provider Demographics
NPI:1770571804
Name:ROBERTSON, JOHN YEARDLEY (DO)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:YEARDLEY
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1478 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3687
Mailing Address - Country:US
Mailing Address - Phone:740-344-6871
Mailing Address - Fax:
Practice Address - Street 1:1478 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3687
Practice Address - Country:US
Practice Address - Phone:740-366-1648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-8001-R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000343448OtherANTHEM
OH7252573OtherAETNA
OH2497927Medicaid
OHI18853Medicare UPIN
OH7252573OtherAETNA
OHDC6099Medicare PIN