MEDICARE: DR. ROBERT LEE OLDHAM M.D.

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	2083P0901X	Public Health & General Preventive Medicine Physician	A112080	CA
2	2084P0800X	Psychiatry Physician	A112080	CA
3	2084P0015X	Psychosomatic Medicine Physician	A112080	CA

General Provider Information

NPI Number	:	1356379507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT LEE OLDHAM M.D.

Provider Business Mailing Address
First Line	:	2625 E DIVISADERO ST
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93721-1431
Country	:	US
Telephone Number	:	559-443-2682
Fax Number	:	559-443-2681

Provider Business Practice Location Address
First Line	:	142 E CALIFORNIA AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93706-3642
Country	:	US
Telephone Number	:	559-600-1033
Fax Number	:	559-600-1101

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	06/30/2014

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