Healthcare Provider Details

I. General information

NPI: 1417197443
Provider Name (Legal Business Name): GREGORY A ROBERTSON MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20311 SW ACACIA ST STE 100
NEWPORT BEACH CA
92660-1733
US

IV. Provider business mailing address

20311 SW ACACIA ST STE 100
NEWPORT BEACH CA
92660-1733
US

V. Phone/Fax

Practice location:
  • Phone: 949-891-1441
  • Fax: 949-878-4845
Mailing address:
  • Phone: 949-891-1441
  • Fax: 949-878-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG50555
License Number StateCA

VIII. Authorized Official

Name: DR. GREGORY A ROBERTSON
Title or Position: CEO
Credential: M.D.
Phone: 949-891-1441