Provider Demographics
NPI:1407123037
Name:ANDERSON, DEMETRIUS (DC)
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
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 3429
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-3429
Mailing Address - Country:US
Mailing Address - Phone:312-225-5550
Mailing Address - Fax:312-225-0999
Practice Address - Street 1:2334 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2105
Practice Address - Country:US
Practice Address - Phone:312-225-5550
Practice Address - Fax:312-225-0999
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor