Provider Demographics
NPI:1477005254
Name:ANDERSON, DONALD JR
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 JACKSON RD STE D
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-1867
Mailing Address - Country:US
Mailing Address - Phone:734-635-7187
Mailing Address - Fax:734-433-1989
Practice Address - Street 1:5060 JACKSON RD STE D
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-1867
Practice Address - Country:US
Practice Address - Phone:734-627-8001
Practice Address - Fax:734-433-1989
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004901225200000X
MI75010003128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant