Provider Demographics
NPI:1790750065
Name:ROBERSON, LEE DOUGLASS (MD)
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:DOUGLASS
Last Name:ROBERSON
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:901-226-3186
Mailing Address - Fax:901-226-3160
Practice Address - Street 1:255 BAPTIST BLVD STE 405
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2004
Practice Address - Country:US
Practice Address - Phone:662-244-2288
Practice Address - Fax:662-244-2289
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14609208G00000X
AL00019855208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009960240Medicaid
AL02404Medicare ID - Type Unspecified
AL009960240Medicaid