Provider Demographics
NPI:1497173470
Name:ANDERSON, DAVID W
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:ANDERSON
Suffix:
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 1:26 UNION ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676-1303
Mailing Address - Country:US
Mailing Address - Phone:802-244-6403
Mailing Address - Fax:802-244-1486
Practice Address - Street 1:26 UNION ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1303
Practice Address - Country:US
Practice Address - Phone:802-244-6403
Practice Address - Fax:802-244-1486
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0154313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility