1619018462 NPI number — DR. HOWARD LAMAR ROBERTSON

Table of content: DR. HOWARD LAMAR ROBERTSON (NPI 1619018462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619018462 NPI number — DR. HOWARD LAMAR ROBERTSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
HOWARD
Provider Middle Name:
LAMAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1619018462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1697
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38902-1697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-614-5070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60024 OLIVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38870-9719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-651-7111
Provider Business Practice Location Address Fax Number:
662-651-7115
Provider Enumeration Date:
02/12/2007

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: 122300000X , with the licence number:  1912-80 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00064850 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com