1891761698 NPI number — DR. GARY L ANDERSON D.O.

Table of content: DR. GARY L ANDERSON D.O. (NPI 1891761698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891761698 NPI number — DR. GARY L ANDERSON D.O.

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891761698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3533 SOUTHERN BLVD STE 2250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETTERING
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45429-1270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-534-0330
Provider Business Mailing Address Fax Number:
937-522-8995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3533 SOUTHERN BLVD
Provider Second Line Business Practice Location Address:
SUITE 2250
Provider Business Practice Location Address City Name:
KETTERING
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45429-1264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-534-0330
Provider Business Practice Location Address Fax Number:
937-534-0340
Provider Enumeration Date:
02/23/2006

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: 208600000X , with the licence number:  34-00-4496A , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0883021 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".