Healthcare Provider Details

I. General information

NPI: 1598024986
Provider Name (Legal Business Name): JORDAN ANDREW ROBERTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 JUDGE TANNER BLVD
COVINGTON LA
70433-7500
US

IV. Provider business mailing address

PO BOX 3780
TUPELO MS
38803-3780
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-4046
  • Fax:
Mailing address:
  • Phone: 318-841-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number566797
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number308024
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: