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General NPI Number Information
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NPI Number | 1770511578
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Entity Type | Individual
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Provider Name | JOHN WARREN ROBERTSON III MD
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Gender | Male
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Dates
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Enumeration Date | 06/29/2006
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Last Update Date | 01/04/2021
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Provider Practice Location Address
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Address Line | 501 GOPHER DR
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City | TOMAH
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State | WI
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Zip | 54660-4513
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Country | US
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Telephone | 608-372-2181
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Fax |
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Provider Business Mailing Address
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Address Line | 501 GOPHER DR
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City | TOMAH
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State | WI
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Zip | 54660-4513
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Country | US
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Telephone | 608-372-2181
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | MD044947E
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License Number State | PA
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