Provider Demographics
NPI:1366490773
Name:ANDERSON, JOHN ROGER (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROGER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8611 W EAGLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-9565
Mailing Address - Country:US
Mailing Address - Phone:208-664-4455
Mailing Address - Fax:208-664-4159
Practice Address - Street 1:8611 W EAGLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-9565
Practice Address - Country:US
Practice Address - Phone:208-664-4455
Practice Address - Fax:208-664-4159
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022041692085R0202X
IDO-03492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000WCGKVAMedicare ID - Type Unspecified
E33771Medicare UPIN