Provider Demographics
NPI:1073614574
Name:ANDERSON, NEVILLE WALLIS (MD)
Entity Type:Individual
Prefix:
First Name:NEVILLE
Middle Name:WALLIS
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N LARCHMONT BLVD
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-6410
Mailing Address - Country:US
Mailing Address - Phone:323-960-8500
Mailing Address - Fax:323-960-8585
Practice Address - Street 1:321 N LARCHMONT BLVD
Practice Address - Street 2:SUITE 1020
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-6410
Practice Address - Country:US
Practice Address - Phone:323-960-8500
Practice Address - Fax:323-960-8585
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics