Provider Demographics
NPI:1255491635
Name:ANDERSON, DEREK NATHAN (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:NATHAN
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 1:454 OLD STREET RD STE 207
Mailing Address - Street 2:
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1200
Mailing Address - Country:US
Mailing Address - Phone:603-924-4664
Mailing Address - Fax:603-924-8653
Practice Address - Street 1:454 OLD STREET RD STE 207
Practice Address - Street 2:
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1253
Practice Address - Country:US
Practice Address - Phone:603-924-4664
Practice Address - Fax:603-924-8653
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD169675207Q00000X
IA36375207Q00000X
NH20947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500682438Medicaid
ORR179802Medicare PIN
OR500682438Medicaid