Provider Demographics
NPI:1043252992
Name:ANDERSON, ROBERT RALPH (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RALPH
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 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-571-6622
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-577-4444
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA243602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A243600Medicaid
CA00A2436014Medicare PIN
CA00A2436010Medicare PIN
CA00A243602Medicare PIN
CA00A243604Medicare PIN
CA00A243603Medicare PIN
CA00A243605Medicare PIN
CAA23942Medicare UPIN
CA300024659Medicare PIN
CA00A2436013Medicare PIN
CA00A243601Medicare PIN
CA00A2436015Medicare PIN
CA00A243608Medicare PIN
CA00A243609Medicare PIN
CA00A2436011Medicare PIN
CA00A2436012Medicare PIN
CA00A243606Medicare PIN
CA00A243607Medicare PIN