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General NPI Number Information
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NPI Number | 1780112276
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Entity Type | Individual
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Provider Name | BRENT JUSTIN ROBERTSON MD
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Gender | Male
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Dates
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Enumeration Date | 05/26/2017
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 500 MEDICAL CENTER BLVD STE 365
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City | CONROE
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State | TX
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Zip | 77304-2889
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Country | US
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Telephone | 936-207-2566
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Fax | 936-207-2586
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Provider Business Mailing Address
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Address Line | 18450 HIGHWAY 59 N
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City | HUMBLE
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State | TX
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Zip | 77338-4404
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Country | US
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Telephone | 281-446-6656
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Fax | 281-446-6657
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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 | 25MA11500000
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License Number State | NJ
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