Provider Demographics
NPI:1396716189
Name:ROBERTSON, CHARLES PAUL (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:PAUL
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 BLACK BEAR WAY
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5514
Mailing Address - Country:US
Mailing Address - Phone:928-368-5493
Mailing Address - Fax:
Practice Address - Street 1:5658 HIGHWAY 260
Practice Address - Street 2:SUITE 24
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5189
Practice Address - Country:US
Practice Address - Phone:928-537-4379
Practice Address - Fax:928-537-4653
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ203406Medicaid
AZ203406Medicaid
AZ104889Medicare ID - Type Unspecified