1417995291 NPI number — DR. WILLIAM DOUGLAS ANDERSON MD

Table of content: DR. WILLIAM DOUGLAS ANDERSON MD (NPI 1417995291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417995291 NPI number — DR. WILLIAM DOUGLAS ANDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
WILLIAM
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
WILLIAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1417995291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
861 SW 78TH AVE
Provider Second Line Business Mailing Address:
SUITE 100B
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-3229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-693-0000
Provider Business Mailing Address Fax Number:
954-693-0005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 N WOOD ST
Provider Second Line Business Practice Location Address:
EMERGENCY DEPARTMENT
Provider Business Practice Location Address City Name:
GILMER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75644-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-841-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2006

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: 207P00000X , with the licence number:  H3365 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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