Provider Demographics
NPI:1073710828
Name:ANDERSON, C NEVIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:C
Middle Name:NEVIN
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CONDE
Other - Middle Name:NEVIN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:601 E SAN ANTONIO ST STE 203W
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6051
Mailing Address - Country:US
Mailing Address - Phone:361-573-6371
Mailing Address - Fax:361-573-7961
Practice Address - Street 1:601 E SAN ANTONIO ST STE 203W
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6051
Practice Address - Country:US
Practice Address - Phone:361-573-6371
Practice Address - Fax:361-573-7961
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8G6950OtherBLUE CROSS BLUE SHIELD
D74265Medicare UPIN
8F1803Medicare ID - Type Unspecified