Provider Demographics
NPI:1235101940
Name:ANDERSON, JOHN J (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:J
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:2301 INDIAN WELLS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4607
Mailing Address - Country:US
Mailing Address - Phone:575-434-0639
Mailing Address - Fax:575-434-4148
Practice Address - Street 1:2301 INDIAN WELLS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4607
Practice Address - Country:US
Practice Address - Phone:575-434-0639
Practice Address - Fax:575-434-4148
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM284213E00000X, 213EP1101X, 213ES0000X, 213ES0103X, 213ER0200X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201038108OtherPRESBYTERIAN HEALTH PLAN
NM000L1222Medicaid
NMNM005A02OtherBLUE CROSS BLUE SHIELD ID
NMU90748Medicare UPIN