Provider Demographics
NPI:1174533509
Name:ROBERTSON, GLENN GARY (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:GARY
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 1:1069 S HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-7008
Mailing Address - Country:US
Mailing Address - Phone:520-720-6226
Mailing Address - Fax:877-795-9311
Practice Address - Street 1:1069 S HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-7008
Practice Address - Country:US
Practice Address - Phone:520-720-6226
Practice Address - Fax:877-795-9311
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ883753Medicaid
AZ883753Medicaid
AZZ83550Medicare ID - Type Unspecified