Provider Demographics
NPI:1003831397
Name:ANDERSON, SHAWN C (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 15TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4130
Mailing Address - Country:US
Mailing Address - Phone:601-553-2000
Mailing Address - Fax:601-553-6873
Practice Address - Street 1:2024 15TH ST FL 2
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4130
Practice Address - Country:US
Practice Address - Phone:601-553-2000
Practice Address - Fax:601-553-6873
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120272Medicaid
MS1110400001Medicare NSC
MS00120272Medicaid
MS512I080126Medicare PIN