Basic Information
| Provider Information | |||||||||
| NPI: | 1346202579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JERRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822711 | ||||||||
| FaxNumber: | 4692820996 | ||||||||
| Practice Location | |||||||||
| Address1: | 2604 ST MICHAEL DR | ||||||||
| Address2: | STE 410 | ||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145430 | ||||||||
| FaxNumber: | 9036145464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 01/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | G0817 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | C5231 | AR | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 124648002 | 05 | TX | MEDICAID | 54444 | 01 | AR | BCBS | OTHER | 103412001 | 05 | AR | MEDICAID | 124648005 | 05 | TX | MEDICAID |