Provider Demographics
NPI:1871607812
Name:ROBERSON, JOHN BOONE SR
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BOONE
Last Name:ROBERSON
Suffix:SR
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 1:811 SOUTH 28TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-261-2611
Mailing Address - Fax:601-261-2711
Practice Address - Street 1:811 SOUTH 28TH AVENUE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-261-2611
Practice Address - Fax:601-261-2711
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2746931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660451Medicaid
MS01951327Medicaid