Basic Information
| Provider Information | |||||||||
| NPI: | 1720021363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAULERSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MACKINNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST. | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188126603 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 OLIVER RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712015702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188074951 | ||||||||
| FaxNumber: | 3188120808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 018874 | LA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1374580 | 05 | LA | MEDICAID |