Provider Demographics
NPI:1912957242
Name:ROBERTSON, JOHN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
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 1:801 11TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4100
Mailing Address - Country:US
Mailing Address - Phone:707-263-7310
Mailing Address - Fax:
Practice Address - Street 1:801 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4100
Practice Address - Country:US
Practice Address - Phone:707-263-7310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC21401207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C214010Medicare ID - Type Unspecified
CAA31922Medicare UPIN