Provider Demographics
NPI:1407867849
Name:ANDRESON, JAMES LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LAWRENCE
Last Name:ANDRESON
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 1:131 OLD ROAD TO 9 ACRE COR
Mailing Address - Street 2:SUITE 530
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4181
Mailing Address - Country:US
Mailing Address - Phone:978-369-0223
Mailing Address - Fax:978-371-1226
Practice Address - Street 1:131 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:SUITE 530
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4181
Practice Address - Country:US
Practice Address - Phone:978-369-0223
Practice Address - Fax:978-371-1226
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6186653Medicaid
B06022Medicare ID - Type Unspecified
B72600Medicare UPIN