Provider Demographics
NPI:1174681670
Name:ANDERSON, MARVIN G (DC)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 1ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5140
Mailing Address - Country:US
Mailing Address - Phone:408-842-4388
Mailing Address - Fax:408-842-8686
Practice Address - Street 1:66 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5140
Practice Address - Country:US
Practice Address - Phone:408-842-4388
Practice Address - Fax:408-842-8686
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21634111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0216340Medicare UPIN