Provider Demographics
NPI:1063409001
Name:ANDERSON, ROBERT DALE (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DALE
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 1:1300 W TERRELL AVE
Mailing Address - Street 2:#500
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2800
Mailing Address - Country:US
Mailing Address - Phone:817-252-5000
Mailing Address - Fax:817-252-5060
Practice Address - Street 1:1300 W TERRELL AVE
Practice Address - Street 2:#500
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2800
Practice Address - Country:US
Practice Address - Phone:817-252-5000
Practice Address - Fax:817-252-5060
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2211207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00246112OtherRAIL ROAD MEDICARE
TX1326811-02Medicaid
TX85V815OtherBLUE CROSS
TXF24686Medicare UPIN
TX85V815Medicare PIN
TXP00246112OtherRAIL ROAD MEDICARE