Provider Demographics
NPI:1437172533
Name:ANDERSON, KENNETH L III (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 GARNET AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4292
Mailing Address - Country:US
Mailing Address - Phone:858-224-7977
Mailing Address - Fax:858-224-7978
Practice Address - Street 1:1945 GARNET AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3595
Practice Address - Country:US
Practice Address - Phone:858-224-7977
Practice Address - Fax:858-224-7978
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5441207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF01223OtherUPIN