Basic Information
Provider Information | |||||||||
NPI: | 1871578500 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTSON | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 497 | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | AR | ||||||||
PostalCode: | 720060497 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703472534 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 114 RAY ST | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | AR | ||||||||
PostalCode: | 721124260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705232944 | ||||||||
FaxNumber: | 8705232998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2005 | ||||||||
LastUpdateDate: | 03/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-2356 | AR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5L325 | 01 | AR | BCBS | OTHER | 138481001 | 05 | AR |   | MEDICAID | P00780865 | 01 | AR | RAILROAD MCARE THRU WMCM | OTHER | P00780865 | 01 | AR | RAILROAD MCARE THRU WCMC | OTHER |