Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 7653 | IN |
Y | 213EG0000X | General Practice | 7653 | IN |
NPI | 1003904806 |
---|---|
Provider Name | Forest Richard Robertson II |
First Address | Monticello, IN 47960-2532 |
Second Address | Monticello, IN 47960 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 08/07/2007 |