Healthcare Provider Details

I. General information

NPI: 1033181003
Provider Name (Legal Business Name): ROBERT DEWEY VANDENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4044 15TH AVE SE SUITE A
LACEY WA
98503-6962
US

IV. Provider business mailing address

1450 NORTHWEST LANE SE SUITE A
LACEY WA
98503-6962
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4460
  • Fax: 360-491-3090
Mailing address:
  • Phone: 360-491-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD00028460
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: