Provider Demographics
NPI:1871578500
Name:ROBERTSON, JONATHAN C (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:
Practice Address - Street 1:114 RAY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-4260
Practice Address - Country:US
Practice Address - Phone:870-523-2944
Practice Address - Fax:870-523-2998
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2356207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5L325OtherBCBS
AR138481001Medicaid
ARP00780865OtherRAILROAD MCARE THRU WMCM
ARP00780865OtherRAILROAD MCARE THRU WCMC
ARP00780865OtherRAILROAD MCARE THRU WCMC
AR5L325B637Medicare PIN
H02498Medicare UPIN