Provider Demographics
NPI:1043296692
Name:ANDERSON, COREY H (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:H
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:PO BOX 200993
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77216-0993
Mailing Address - Country:US
Mailing Address - Phone:281-784-1111
Mailing Address - Fax:281-784-1555
Practice Address - Street 1:4000 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1202
Practice Address - Country:US
Practice Address - Phone:713-359-2000
Practice Address - Fax:713-359-1004
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8440207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1043296692OtherTRICARE SOUTH
TX8G4151OtherBCBSTX PROV NO
TX139376117Medicaid
TX930117319Medicare PIN
TX1043296692OtherTRICARE SOUTH
TXG18455Medicare UPIN