Provider Demographics
NPI:1235130709
Name:ANDERSON, WILLIAM ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ROBERT
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:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:GORE
Mailing Address - State:OK
Mailing Address - Zip Code:74435
Mailing Address - Country:US
Mailing Address - Phone:918-489-5757
Mailing Address - Fax:918-489-5411
Practice Address - Street 1:700 N MAIN
Practice Address - Street 2:
Practice Address - City:GORE
Practice Address - State:OK
Practice Address - Zip Code:74435
Practice Address - Country:US
Practice Address - Phone:918-489-5757
Practice Address - Fax:918-489-5411
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100257880AMedicaid
OK100257880CMedicaid
OK100257880EMedicaid
OKE07693Medicare UPIN
OK100257880CMedicaid