Provider Demographics
NPI:1033169321
Name:ANDERSON, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W CRANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2930
Mailing Address - Country:US
Mailing Address - Phone:229-247-7350
Mailing Address - Fax:229-242-1730
Practice Address - Street 1:105 W CRANFORD AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2930
Practice Address - Country:US
Practice Address - Phone:229-247-7350
Practice Address - Fax:229-242-1730
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0250932080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264389800Medicaid
GA00271543AMedicaid
GA202I370889OtherMEDICARE PART B