Provider Demographics
NPI:1033236930
Name:ANDERSON, JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
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 1:5410 SHERIDAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702
Mailing Address - Country:US
Mailing Address - Phone:605-348-4141
Mailing Address - Fax:605-342-7880
Practice Address - Street 1:5410 SHERIDAN LAKE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702
Practice Address - Country:US
Practice Address - Phone:605-348-4141
Practice Address - Fax:605-342-7880
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3977207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F64954Medicare UPIN