Provider Demographics
NPI:1790034296
Name:ROBERTSON, GARY (IDC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 USS MARIANO VILLEJO AVE
Mailing Address - Street 2:
Mailing Address - City:KINGS BAY
Mailing Address - State:GA
Mailing Address - Zip Code:31547
Mailing Address - Country:US
Mailing Address - Phone:912-573-6599
Mailing Address - Fax:
Practice Address - Street 1:1059 USS MARIANO VILLEJO AVE
Practice Address - Street 2:
Practice Address - City:KINGS BAY
Practice Address - State:GA
Practice Address - Zip Code:31547
Practice Address - Country:US
Practice Address - Phone:912-573-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1132OtherUS NAVY