Provider Demographics
NPI:1497643613
Name:ROBERTSON, ROGER BRIAN
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:BRIAN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S DEPOT MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JUDSONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72081-9580
Mailing Address - Country:US
Mailing Address - Phone:501-283-6772
Mailing Address - Fax:
Practice Address - Street 1:302 S DEPOT MAIN ST
Practice Address - Street 2:
Practice Address - City:JUDSONIA
Practice Address - State:AR
Practice Address - Zip Code:72081-9580
Practice Address - Country:US
Practice Address - Phone:501-283-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant