Basic Information
| Provider Information | |||||||||
| NPI: | 1033181003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDENBERG | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | DEWEY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 NORTHWEST LANE SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985036962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604914460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4044 15TH AVE SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985036962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604914460 | ||||||||
| FaxNumber: | 3604913090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | MD00028460 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.