Provider Demographics
NPI:1427012632
Name:ANDERSON, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
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 1:701 OSTRUM ST.
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015
Mailing Address - Country:US
Mailing Address - Phone:610-691-0351
Mailing Address - Fax:610-691-4131
Practice Address - Street 1:701 OSTRUM ST.
Practice Address - Street 2:SUITE 401
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015
Practice Address - Country:US
Practice Address - Phone:610-691-0351
Practice Address - Fax:610-691-4131
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030460L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0696748Medicaid
PA0696748Medicaid
PAD71293Medicare UPIN
PA147818Medicare ID - Type Unspecified