=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457382731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR ANDREA ROBERSON D.O. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 10/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 AVENIDA DE LA ESTRELLA STE 1A
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-586-8000
-----------------------------------------------------
Fax | 949-429-8829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 AVENIDA DE LA ESTRELLA STE 1A
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-586-8000
-----------------------------------------------------
Fax | 949-429-8829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANDREA ROBERSON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 949-586-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20A4958
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------