Provider Demographics
NPI:1578556155
Name:ANDERSON, ROBERT PATRICK (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PATRICK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-339-5422
Mailing Address - Fax:425-339-5444
Practice Address - Street 1:3927 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4833
Practice Address - Country:US
Practice Address - Phone:425-339-5422
Practice Address - Fax:425-339-5444
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001534A207QS0010X
IN02001534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02001534OtherIN LICENSE
IN000000581128OtherANTHEM PIN
IN1225327984OtherGROUP NPI
IN90001186OtherBC IL
INM100047140OtherMEDICARE GROUP PTAN
INM100047140OtherMEDICARE GROUP PTAN
IN90001186OtherBC IL