Provider Demographics
NPI:1124406186
Name:ANDERSON, MICHAEL A (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
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 1:1489 PARTRIDGE CV
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1988
Mailing Address - Country:US
Mailing Address - Phone:208-648-4789
Mailing Address - Fax:208-648-4790
Practice Address - Street 1:1000 POCATELLO CREEK RD STE E10
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2953
Practice Address - Country:US
Practice Address - Phone:208-648-4789
Practice Address - Fax:208-648-4790
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X, 390200000X
IDO-1136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1124406816Medicaid