Provider Demographics
NPI:1770718298
Name:ROBERTSON, PAUL (MS, RDN, LDN)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WEST WOODROW WILSON AVENUE
Mailing Address - Street 2:AMBULATORY SERVICES - OUTPATIENT DIETITIAN
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:601-815-2500
Mailing Address - Fax:601-984-4074
Practice Address - Street 1:350 WEST WOODROW WILSON AVENUE
Practice Address - Street 2:AMBULATORY SERVICES - OUTPATIENT DIETITIAN
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-815-2500
Practice Address - Fax:601-984-4074
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1361133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I717177Medicare PIN