Provider Demographics
NPI:1871792051
Name:ROBERTSON, ADRIENNE C (MD)
Entity type:Individual
Prefix:DR
First Name:ADRIENNE
Middle Name:C
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 1:1001 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-3227
Mailing Address - Country:US
Mailing Address - Phone:985-492-9111
Mailing Address - Fax:985-492-9114
Practice Address - Street 1:1001 JACKSON ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-3227
Practice Address - Country:US
Practice Address - Phone:985-492-9111
Practice Address - Fax:985-492-9114
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11130207Q00000X
LAMD.206930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2371231Medicaid