Provider Demographics
NPI:1841250156
Name:ROBERTSON, JOHN DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOUGLAS
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 1:6727 TAYLOR COURT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7708
Mailing Address - Country:US
Mailing Address - Phone:334-284-2800
Mailing Address - Fax:334-284-0438
Practice Address - Street 1:6727 TAYLOR COURT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7708
Practice Address - Country:US
Practice Address - Phone:334-284-2800
Practice Address - Fax:334-284-0438
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24023174400000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051553528Medicaid
AL051515857OtherBLUE CROSS BLUE SHIELD
AL15857OtherBC/BS PROVIDER #
AL15857OtherBC/BS PROVIDER #
051553528Medicare PIN