Provider Demographics
NPI:1457452922
Name:ANDERSON, CARROL L JR (MD)
Entity Type:Individual
Prefix:
First Name:CARROL
Middle Name:L
Last Name:ANDERSON
Suffix:JR
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 1:3302 BOCA CHICA BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-4271
Mailing Address - Country:US
Mailing Address - Phone:956-982-1001
Mailing Address - Fax:956-982-1938
Practice Address - Street 1:3302 BOCA CHICA BLVD STE 109
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-4271
Practice Address - Country:US
Practice Address - Phone:956-982-1001
Practice Address - Fax:956-982-1938
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6390207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172803202OtherMEDICAID TEXAS HEALTH STEPS NUMBER
TX140145728Medicaid
TX172803201OtherMEDICAID GROUP NUMBER
TX00345YOtherMEDICARE GROUP NUMBER
TX00345YOtherMEDICARE GROUP NUMBER
TX8D2729Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE