MEDICARE: ROBERT LOUIS MANDIBERG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	G67402	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	OOG674020	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1336130640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT LOUIS MANDIBERG

Provider Business Mailing Address
First Line	:	4301 NORTHSTAR WAY
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95356-9262
Country	:	US
Telephone Number	:	209-342-2300
Fax Number	:	209-524-4240

Provider Business Practice Location Address
First Line	:	5555 W LAS POSITAS BLVD
Second Line	:
City	:	PLEASANTON
State	:	CA
Zip	:	94588-4000
Country	:	US
Telephone Number	:	209-342-2300
Fax Number	:	209-524-4240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/08/2007

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