Provider Demographics
NPI:1477620128
Name:ANDERSEN, CARLOS E (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:E
Last Name:ANDERSEN
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 1:3301 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-2820
Mailing Address - Country:US
Mailing Address - Phone:925-685-3020
Mailing Address - Fax:925-685-5017
Practice Address - Street 1:3301 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2820
Practice Address - Country:US
Practice Address - Phone:925-685-3020
Practice Address - Fax:925-685-5017
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A295320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA295320Medicare UPIN
CA00A295320Medicare ID - Type UnspecifiedMEDICARE #