Healthcare Provider Details

I. General information

NPI: 1003811332
Provider Name (Legal Business Name): ROBERT DAVID JANSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 460
MARIETTA GA
30060-1171
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 460
MARIETTA GA
30060-1171
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-7389
  • Fax: 770-427-2845
Mailing address:
  • Phone: 770-427-7389
  • Fax: 770-427-2845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberGA027578
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: