Provider Demographics
NPI:1578556155
Name:ANDERSON, ROBERT PATRICK (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PATRICK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:541-734-9885
Practice Address - Street 1:1600 DELTA WATERS RD STE 107
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9114
Practice Address - Country:US
Practice Address - Phone:541-858-2515
Practice Address - Fax:541-858-2514
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001534A207QS0010X
ORDO220338207Q00000X
IN02001534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02001534OtherIN LICENSE
OR500838253Medicaid
ORDO220338OtherOREGON MEDICAL LICENSE
INM100047140OtherMEDICARE GROUP PTAN
IN90001186OtherBC IL
IN1225327984OtherGROUP NPI
IN000000581128OtherANTHEM PIN