Provider Demographics
NPI:1326064270
Name:ANDERSON, ROBERT G (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:ANDERSON
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 1:800 12TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2519
Mailing Address - Country:US
Mailing Address - Phone:817-810-0770
Mailing Address - Fax:817-820-0242
Practice Address - Street 1:800 12TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2519
Practice Address - Country:US
Practice Address - Phone:817-810-0770
Practice Address - Fax:817-820-0242
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE41762086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
240008036OtherRAILROAD MEDICARE
240008036OtherRAILROAD MEDICARE