Provider Demographics
NPI:1275657348
Name:ANDERSON, JAMES LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LEE
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 1:707 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1732
Mailing Address - Country:US
Mailing Address - Phone:218-724-7646
Mailing Address - Fax:
Practice Address - Street 1:707 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1732
Practice Address - Country:US
Practice Address - Phone:218-724-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN255602080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND80247Medicare UPIN