Provider Demographics
NPI:1437331733
Name:ANDERSON, NICOLE SUNDERLAND (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUNDERLAND
Last Name:ANDERSON
Suffix:
Gender:F
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:PO BOX 19675
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9675
Mailing Address - Country:US
Mailing Address - Phone:904-309-8680
Mailing Address - Fax:904-345-5841
Practice Address - Street 1:1235 SAN MARCO BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8554
Practice Address - Country:US
Practice Address - Phone:904-202-7020
Practice Address - Fax:904-202-7029
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1115582085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003120545AMedicaid
FL004305000Medicaid
FL14J0NOtherBCBS
FL351861OtherAVMED
FLFR260UMedicare PIN
FL004305000Medicaid
FLFR260QMedicare PIN
FL14J0NOtherBCBS
FLFR260RMedicare PIN
FL351861OtherAVMED
FLFR260VMedicare PIN
FLFR260XMedicare PIN
FLFR260YMedicare PIN
FLFR260SMedicare PIN