Provider Demographics
NPI:1114951480
Name:ANDERSON, KIRK LOGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:LOGAN
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 1:109 SHULT DR
Mailing Address - Street 2:#102
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-3009
Mailing Address - Country:US
Mailing Address - Phone:979-732-5794
Mailing Address - Fax:979-732-9431
Practice Address - Street 1:109 SHULT DR
Practice Address - Street 2:#102
Practice Address - City:COLUMBUS
Practice Address - State:TX
Practice Address - Zip Code:78934-3009
Practice Address - Country:US
Practice Address - Phone:979-732-5794
Practice Address - Fax:979-732-9431
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5818207Q00000X, 146D00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126889802OtherEPSDT
TX126889804Medicaid
TX010001278OtherRAILROAD MEDICARE
TX1309494-02Medicaid
TX126889802OtherEPSDT
TX126889804Medicaid
TX453415Medicare ID - Type UnspecifiedFOMC - CLINIC BILLING