Provider Demographics
NPI:1447243175
Name:ANDERSON, GARY D (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
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 1:6219 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-9241
Mailing Address - Country:US
Mailing Address - Phone:608-838-4021
Mailing Address - Fax:
Practice Address - Street 1:6219 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:MC FARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-9241
Practice Address - Country:US
Practice Address - Phone:608-838-4021
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22274207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAF14552Medicare UPIN