Provider Demographics
NPI:1366491664
Name:ANDERSON, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-975-6425
Mailing Address - Fax:517-975-2909
Practice Address - Street 1:3520 FOREST RD FL 3
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3720
Practice Address - Country:US
Practice Address - Phone:517-975-6425
Practice Address - Fax:517-975-6430
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010762012085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1366491664Medicaid
MI4637502Medicaid
MI0C36350085Medicare PIN
MI4637502Medicaid