Provider Demographics
NPI:1073974473
Name:ANDERSON, JIM DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:DOUGLAS
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 1:23 GRANITE CT
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4306
Mailing Address - Country:US
Mailing Address - Phone:415-298-6656
Mailing Address - Fax:650-366-9401
Practice Address - Street 1:23 GRANITE CT
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-4306
Practice Address - Country:US
Practice Address - Phone:415-298-6656
Practice Address - Fax:650-366-9401
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29493207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G29493OtherCA MEDICAL LICENCE