Healthcare Provider Details

I. General information

NPI: 1437170933
Provider Name (Legal Business Name): ROBERT A HARDESTY M.D., F.A.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 BROCKTON AVE SUITE 302
RIVERSIDE CA
92506-0102
US

IV. Provider business mailing address

PO BOX 10609
SAN BERNARDINO CA
92423-0609
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-7600
  • Fax: 951-369-9999
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberGO4871
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG40871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: