Provider Demographics
NPI:1467492660
Name:ANDERSON, MARK WESLEY (CPO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WESLEY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-8401
Mailing Address - Country:US
Mailing Address - Phone:731-286-6006
Mailing Address - Fax:731-286-5570
Practice Address - Street 1:1079 VENDALL RD
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1622
Practice Address - Country:US
Practice Address - Phone:731-286-6006
Practice Address - Fax:731-286-5570
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454453Medicaid
4804280001Medicare NSC