Basic Information
| Provider Information | |||||||||
| NPI: | 1962946442 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT B. SANDERS D.O., A PROF. CORP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 516529 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662842771 | ||||||||
| FaxNumber: | 8003341041 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 W MADISON AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920203454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193347542 | ||||||||
| FaxNumber: | 6199382568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2016 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6199224272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 20A5544 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 20A5544 | 01 | CA | MEDICAL LICENSE | OTHER |