Provider Demographics
NPI:1144420951
Name:ANDERSON, GEOFFREY (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
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 1:2051 MORENGO ST
Mailing Address - Street 2:IPT, C5L100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:617-763-6900
Mailing Address - Fax:
Practice Address - Street 1:92 BEACON ST
Practice Address - Street 2:1B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-3325
Practice Address - Country:US
Practice Address - Phone:617-763-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1007892086S0127X
MA247890208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery