Provider Demographics
NPI:1265454623
Name:ANDERSON, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:276 S WILDWOOD
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-3562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:SUTTER SOLANO HOSPITALIST
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2574
Practice Address - Country:US
Practice Address - Phone:707-554-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25337OtherBC CA
CA00A253370OtherBS CA
CA00A253370Medicaid
CA00A253370Medicaid
CA00A253375Medicare ID - Type Unspecified