Provider Demographics
NPI:1043223696
Name:ANDERSON, JEFFREY J (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
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 1:1414 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3328
Mailing Address - Country:US
Mailing Address - Phone:307-682-6263
Mailing Address - Fax:307-682-2024
Practice Address - Street 1:1414 W 4TH ST
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3328
Practice Address - Country:US
Practice Address - Phone:307-682-6263
Practice Address - Fax:307-682-2024
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001719207V00000X
WY8335A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104991Medicaid
WA1104991Medicaid
G12192Medicare UPIN