Provider Demographics
NPI:1871590554
Name:VAN BREDERODE, ROBERT LLOYD (DPM)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LLOYD
Last Name:VAN BREDERODE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 ALTAPASS HWY
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-3001
Mailing Address - Country:US
Mailing Address - Phone:828-766-7667
Mailing Address - Fax:828-766-7668
Practice Address - Street 1:537 ALTAPASS HWY
Practice Address - Street 2:
Practice Address - City:SPRUCE PINE
Practice Address - State:NC
Practice Address - Zip Code:28777-3001
Practice Address - Country:US
Practice Address - Phone:828-766-7667
Practice Address - Fax:828-766-7668
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC479213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC050159Medicaid
NCU86440Medicare UPIN
NC050159Medicaid