1720073869 NPI number — JEFFREY ROBERTSON OD

Table of content: JEFFREY ROBERTSON OD (NPI 1720073869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720073869 NPI number — JEFFREY ROBERTSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
JEFFREY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1720073869
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/23/2006
NPI Reactivation Date:
03/28/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WINTERVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23434-7669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-539-0615
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 COLISEUM XING SPC 58
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23666-5971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-751-6236
Provider Business Practice Location Address Fax Number:
757-838-1840
Provider Enumeration Date:
09/14/2005

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: 152W00000X , with the licence number:  0618000334 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9204300 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com