1982702114 NPI number — DR. KELLY D ANDERSON OD

Table of content: DR. KELLY D ANDERSON OD (NPI 1982702114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982702114 NPI number — DR. KELLY D ANDERSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
KELLY
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1982702114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 61199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33906-1199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-418-0262
Provider Business Mailing Address Fax Number:
239-274-0773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 PIPER BLVD
Provider Second Line Business Practice Location Address:
SUITE 22
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34110-1380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-734-3877
Provider Business Practice Location Address Fax Number:
239-734-3879
Provider Enumeration Date:
09/20/2006

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: 152WC0802X , with the licence number:  OPC 3770 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 620851700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23001 . This is a "BCBS NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OPC3770 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com