Provider Demographics
NPI:1114003415
Name:ANTHONY, ALAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:J
Last Name:ANTHONY
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 1:1025 MICHIGAN AVE
Mailing Address - Street 2:STE 215
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1593
Mailing Address - Country:US
Mailing Address - Phone:574-753-2222
Mailing Address - Fax:574-753-0522
Practice Address - Street 1:1025 MICHIGAN AVE
Practice Address - Street 2:STE 215
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1593
Practice Address - Country:US
Practice Address - Phone:574-753-2222
Practice Address - Fax:574-753-0522
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15007207N00000X, 207Q00000X
IN01054521A207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200280770Medicaid
IN000000970192OtherANTHEM
INP01578225OtherRAILROAD MEDICARE
NV002003058Medicaid
IN200280770Medicaid