Provider Demographics
NPI:1689681595
Name:VANDERGRAAF, ROBERT CORNELES (DO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CORNELES
Last Name:VANDERGRAAF
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 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-554-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9081207L00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX90810Medicaid
CA020A90810OtherBLUE SHIELD OF CALIFORNIA
CA020A90810Medicare PIN