Provider Demographics
NPI:1437170933
Name:HARDESTY, ROBERT A (MD, FACS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:HARDESTY
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10609
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0102
Practice Address - Country:US
Practice Address - Phone:951-686-7600
Practice Address - Fax:951-369-9999
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO4871174400000X
CAG40871208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist