Provider Demographics
NPI:1356325039
Name:ANDERSON, KATHY IRENE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:IRENE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 ARMSTRONG DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:MI
Mailing Address - Zip Code:49037
Mailing Address - Country:US
Mailing Address - Phone:269-966-5600
Mailing Address - Fax:
Practice Address - Street 1:1765 BALLARD DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-2879
Practice Address - Country:US
Practice Address - Phone:903-485-6100
Practice Address - Fax:903-785-6105
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1603213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5389300001Medicare NSC
TX8F3726Medicare PIN