Provider Demographics
NPI:1366434342
Name:ROBERTSON, ROY W (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:W
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-9520
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037760A207R00000X, 207RC0000X, 208600000X, 2086S0129X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000641097OtherANTHEM
INP00782372OtherR.R. MEDICARE
IN060070573OtherRR MEDICARE
OH0977117Medicaid
IN100465520Medicaid
IN000000641097OtherANTHEM
IN193590OMedicare PIN
INP00782372OtherR.R. MEDICARE
IN100465520Medicaid
IN060070573Medicare PIN