Basic Information
| Provider Information | |||||||||
| NPI: | 1659329233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTSON | ||||||||
| OtherFirstName: | GREG | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934650087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 LAS TABLAS RD | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934659704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054343500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | A76912 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | A76912 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A769120 | 05 | CA | MEDICAID | P00169429 | 01 | CA | MEDICARE RAILROAD | OTHER |