Provider Demographics
NPI:1366445462
Name:ANDERSON, EDWARD (DPM)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
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:PO BOX 1593
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1593
Mailing Address - Country:US
Mailing Address - Phone:270-830-6522
Mailing Address - Fax:
Practice Address - Street 1:411 LETCHER ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4245
Practice Address - Country:US
Practice Address - Phone:270-830-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0197213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00733506OtherRAILROAD MEDICARE
IN100381580AMedicaid
KY480034923OtherRAILROAD MEDICARE
KY80001977Medicaid
KYK219810Medicare PIN
INM69211038Medicare PIN
KY480034923OtherRAILROAD MEDICARE
INP00733506OtherRAILROAD MEDICARE