Provider Demographics
NPI:1437119583
Name:ANDERSON, ROBERT GREGORY (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:GREGORY
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 1:1815 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1617
Mailing Address - Country:US
Mailing Address - Phone:229-391-3535
Mailing Address - Fax:229-391-3529
Practice Address - Street 1:1815 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-391-3535
Practice Address - Fax:229-391-3529
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032121208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA270436OtherBLUE CROSS BLUE SHEILD
GA00400375AMedicaid
GA00400375AMedicaid
GA00400375AMedicaid