Healthcare Provider Details

I. General information

NPI: 1396716189
Provider Name (Legal Business Name): CHARLES PAUL ROBERTSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5658 HIGHWAY 260 SUITE 24
LAKESIDE AZ
85929-5189
US

IV. Provider business mailing address

5423 BLACK BEAR WAY
LAKESIDE AZ
85929-5514
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-4379
  • Fax: 928-537-4653
Mailing address:
  • Phone: 928-368-5493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11095
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: