Basic Information
| Provider Information | |||||||||
| NPI: | 1962695304 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT R. ANDERSON M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S ELISEO DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154618200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 S ELISEO DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949042134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154618200 | ||||||||
| FaxNumber: | 4154614627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4154618200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00G305540 | 05 | CA | MEDICAID |