Basic Information
| Provider Information | |||||||||
| NPI: | 1801894225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | MELVIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2540 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712072540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183880810 | ||||||||
| FaxNumber: | 3183880810 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 DEVILLE LN | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712706313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182555020 | ||||||||
| FaxNumber: | 3182556623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2005 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 06868R | LA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1304310 | 05 | LA | MEDICAID |