MEDICARE: DR. DWIGHT A. ROBERTSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	30026	CO

General Provider Information

NPI Number	:	1740276179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWIGHT A. ROBERTSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 38220
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80937-8220
Country	:	US
Telephone Number	:	719-535-8900
Fax Number	:	719-535-8986

Provider Business Practice Location Address
First Line	:	1465 KELLY JOHNSON BLVD
Second Line	:	SUITE 310
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3955
Country	:	US
Telephone Number	:	719-535-8900
Fax Number	:	719-535-8986

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/08/2007

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