Basic Information
| Provider Information | |||||||||
| NPI: | 1386749067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SODERBLOM | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 34394 LA RAYE DR | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923995023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098357084 | ||||||||
| FaxNumber: | 9097773858 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | 111N | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9097773858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G12254 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | AS4562193 | 01 | CA | NARCOTIC | OTHER | G12254 | 01 | CA | MEDICAL LICENSE | OTHER |