Provider Demographics
NPI:1366452856
Name:ANDERSON, R SAMUEL (PT, DPT, OCS)
Entity Type:Individual
Prefix:MR
First Name:R
Middle Name:SAMUEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S DOBSON RD STE 314
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4752
Mailing Address - Country:US
Mailing Address - Phone:480-833-7879
Mailing Address - Fax:480-844-8411
Practice Address - Street 1:1500 S DOBSON RD STE 314
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4752
Practice Address - Country:US
Practice Address - Phone:480-833-7879
Practice Address - Fax:480-844-8411
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7782251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ778OtherLICENSE
AZ778OtherLICENSE