Provider Demographics
NPI:1205886637
Name:ANDERSON, ROBERT L (M D)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:M D
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 3148
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3148
Mailing Address - Country:US
Mailing Address - Phone:855-206-8407
Mailing Address - Fax:
Practice Address - Street 1:951 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2163
Practice Address - Country:US
Practice Address - Phone:321-268-6192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00304962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00467227OtherRR MEDICARE
FL043048000Medicaid
FL93859OtherBCBS PROVIDER NUMBER
FL300040318OtherRR MEDICARE
FLD84876Medicare UPIN
FL300040318OtherRR MEDICARE
FL043048000Medicaid
FL93859Medicare ID - Type UnspecifiedMEDICARE NUMBER