Provider Demographics
NPI:1073716072
Name:ANDERSON, JEFFREY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DEAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF RADIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3700
Mailing Address - Fax:414-805-3777
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF RADIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3700
Practice Address - Fax:414-805-3777
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR8049207R00000X
WI529022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073716072Medicaid