Provider Demographics
NPI:1528154861
Name:ROBERTSON, AUDREY UKACHI (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:UKACHI
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514H E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:601-713-3900
Mailing Address - Fax:601-713-3970
Practice Address - Street 1:514H E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-713-3900
Practice Address - Fax:601-713-3970
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15656208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5355653OtherAETNA
MS00118818Medicaid
MS001819211003OtherUNITED HEALTH CARE
MSG61762Medicare UPIN