Healthcare Provider Details

I. General information

NPI: 1235458027
Provider Name (Legal Business Name): DR. JEFFREY ROBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEFFREY ROBERTSON D.P.M.

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-7419
  • Fax:
Mailing address:
  • Phone: 909-427-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPL 60088829
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPL 60088829
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: