Provider Demographics
NPI:1801874144
Name:ANDERSON, ROBERT LOUIS (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOUIS
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-546-9800
Mailing Address - Fax:707-546-4112
Practice Address - Street 1:1017 2ND ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6608
Practice Address - Country:US
Practice Address - Phone:707-546-9800
Practice Address - Fax:707-546-4112
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49374207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G493740Medicaid
P01035543OtherRAILROAD MEDICARE
00G493740Medicare ID - Type Unspecified
P01035543OtherRAILROAD MEDICARE
CAFV723ZMedicare PIN