Provider Demographics
NPI:1952338600
Name:ROBERSON, ANDREA A (DO)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:A
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 AVENIDA DE LA ESTRELLA STE 1A
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3985
Mailing Address - Country:US
Mailing Address - Phone:949-586-8000
Mailing Address - Fax:949-429-8829
Practice Address - Street 1:105 AVENIDA DE LA ESTRELLA STE 1A
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3985
Practice Address - Country:US
Practice Address - Phone:949-586-8000
Practice Address - Fax:949-429-8829
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93602Medicare UPIN
CA20A4958Medicare ID - Type Unspecified