Provider Demographics
NPI:1780774562
Name:ROBERTSON, KEVIN WALLACE (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WALLACE
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1375 S LAPEER RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1421
Mailing Address - Country:US
Mailing Address - Phone:248-693-9040
Mailing Address - Fax:248-693-9007
Practice Address - Street 1:1375 S LAPEER RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1421
Practice Address - Country:US
Practice Address - Phone:248-693-9040
Practice Address - Fax:248-693-9007
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26258Medicare UPIN