Provider Demographics
NPI:1467483867
Name:ANDERSON, KENNETH ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
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 1:12815 KATHERINE CIR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15701 STATE ROAD 50SUITE 101
Practice Address - Street 2:SUITE 101
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-394-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378592100Medicaid
27731ZMedicare ID - Type Unspecified
FL378592100Medicaid