Provider Demographics
NPI:1043237613
Name:ANDERSON, CONSTANCE L (DO)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 MAPLEWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:304-647-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV80170802OtherRAILROAD MEDICARE
WV5630339000Medicaid
WV5279784OtherFIRST HEALTH
WV045OtherMTST BCBS
WV299233OtherAETNA
WV441905OtherANTHEM BCBS
WV141471OtherSOUTHERN HEALTH
WV029222002OtherCIGNA
WV029222002OtherCIGNA
WVAN4010702Medicare ID - Type Unspecified
WV80170802OtherRAILROAD MEDICARE