Provider Demographics
NPI:1073517959
Name:ANDERSEN, ERIC A (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:ANDERSEN
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-9000
Mailing Address - Fax:515-643-7509
Practice Address - Street 1:800 E 1ST ST STE 2200
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021
Practice Address - Country:US
Practice Address - Phone:515-643-9000
Practice Address - Fax:515-643-7509
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37693208000000X
WI38910208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000930080Medicare ID - Type Unspecified
G90715Medicare UPIN