Provider Demographics
NPI:1164474920
Name:ANDERSON, REGINA (MD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 N CHARLES STREET
Mailing Address - Street 2:SUITE 114
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-889-7600
Mailing Address - Fax:410-889-7699
Practice Address - Street 1:4100 N CHARLES STREET
Practice Address - Street 2:SUITE 114
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-889-7600
Practice Address - Fax:410-889-7699
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD23825207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004266216OtherAETNA
MDD66493Medicare UPIN
MDAW91Medicare PIN
MD1027Medicare ID - Type Unspecified