Provider Demographics
NPI:1235435637
Name:ANDERSON, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4469 GREEN VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-1365
Mailing Address - Country:US
Mailing Address - Phone:707-864-8188
Mailing Address - Fax:707-864-8188
Practice Address - Street 1:4469 GREEN VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-1365
Practice Address - Country:US
Practice Address - Phone:707-864-8188
Practice Address - Fax:707-864-8188
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG19714208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19714OtherMED BOARD OF CALIFORNIA PHYSICIAN & SURGEON