Provider Demographics
NPI:1124400759
Name:ANDERSON, DOUGLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64226
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4226
Mailing Address - Country:US
Mailing Address - Phone:667-214-1720
Mailing Address - Fax:410-706-6976
Practice Address - Street 1:419 W REDWOOD ST STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-7003
Practice Address - Country:US
Practice Address - Phone:410-328-5842
Practice Address - Fax:410-706-6976
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016341208600000X
NY303882208G00000X
MDH0094232208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery