Provider Demographics
NPI:1801894225
Name:ROBERTSON, GERALD MELVIN (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:MELVIN
Last Name:ROBERTSON
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 2540
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-2540
Mailing Address - Country:US
Mailing Address - Phone:318-388-0810
Mailing Address - Fax:318-388-0810
Practice Address - Street 1:904 DEVILLE LN
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6313
Practice Address - Country:US
Practice Address - Phone:318-255-5020
Practice Address - Fax:318-255-6623
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-09
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06868R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1304310Medicaid
LA51541Medicare ID - Type Unspecified
LAB63147Medicare UPIN