Provider Demographics
NPI:1245203926
Name:ANDERSON, IRVIN BURTON (MD)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:BURTON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 BEDFORD AVE
Mailing Address - Street 2:MAPLE MEDICAL OFFICE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5005
Mailing Address - Country:US
Mailing Address - Phone:718-693-6100
Mailing Address - Fax:718-940-4698
Practice Address - Street 1:1847 BEDFORD AVE
Practice Address - Street 2:MAPLE MEDICAL OFFICE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5005
Practice Address - Country:US
Practice Address - Phone:718-693-6100
Practice Address - Fax:718-940-4698
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-11
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137897208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB78915Medicare UPIN
NY67D051Medicare ID - Type Unspecified