Provider Demographics
NPI:1376607150
Name:ANDERSON, JOHN SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SAMUEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 W 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-1636
Mailing Address - Country:US
Mailing Address - Phone:720-891-8322
Mailing Address - Fax:
Practice Address - Street 1:4603 W 32ND AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212-1636
Practice Address - Country:US
Practice Address - Phone:720-891-8322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-22092085R0202X
MO20030141552085R0202X
CO474422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65474091Medicaid
CO020065OtherKAISER COMMERCIAL NUMBER
COP01017683Medicare PIN
CO020065OtherKAISER COMMERCIAL NUMBER
CO65474091Medicaid
COP00799353Medicare PIN