Provider Demographics
NPI:1083670517
Name:ANDERSON, ALLAN A (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:A
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 1:300 BYRN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-1908
Mailing Address - Country:US
Mailing Address - Phone:410-228-5511
Mailing Address - Fax:
Practice Address - Street 1:405 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2421
Practice Address - Country:US
Practice Address - Phone:410-228-7917
Practice Address - Fax:410-228-3580
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD402002084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0653411Medicaid
B10201Medicare UPIN
184P423GMedicare ID - Type Unspecified