Healthcare Provider Details

I. General information

NPI: 1154303105
Provider Name (Legal Business Name): JOHN L ROBERSON JR. DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 ST. VINCENT'S DRIVE SUITE 420
BIRMINGHAM AL
35205-2704
US

IV. Provider business mailing address

805 ST. VINCENT'S DRIVE STE 420
BIRMINGHAM AL
35205-1641
US

V. Phone/Fax

Practice location:
  • Phone: 205-324-8511
  • Fax: 205-324-0319
Mailing address:
  • Phone: 205-324-8511
  • Fax: 205-314-8551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number262
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: