1164730917 NPI number — JED ROBINSON D.O.

Table of content: JED ROBINSON D.O. (NPI 1164730917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164730917 NPI number — JED ROBINSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBINSON
Provider First Name:
JED
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164730917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 BOLLWEEVIL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71203-6504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2106 LOOP RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINNSBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71295-3343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-435-3771
Provider Business Practice Location Address Fax Number:
318-435-7233
Provider Enumeration Date:
09/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  125.056367 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9YJC5 . This is a "MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: DO.000376 . This is a "LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 12666819 . This is a "CAQH" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 2363247 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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