1356328272 NPI number — DR. C. LEROY ANDERSON M.D.

Table of content: DR. C. LEROY ANDERSON M.D. (NPI 1356328272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356328272 NPI number — DR. C. LEROY ANDERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
C.
Provider Middle Name:
LEROY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDERSON
Provider Other First Name:
CLARENCE
Provider Other Middle Name:
LEROY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356328272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1034 N 500 W
Provider Second Line Business Mailing Address:
UTAH VALLEY PSYCHIATRY AND COUNSELING CLINIC
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-3380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-357-7525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1034 N 500 W
Provider Second Line Business Practice Location Address:
UTAH VALLEY PSYCHIATRY AND COUNSELING CLINIC
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-3380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-357-7525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  821686511205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0804X , with the licence number: 821686511205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)