Provider Demographics
NPI:1497728323
Name:ANDERSON, MICKEY DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:DALE
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7840
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:118 PATRIOT DR
Practice Address - Street 2:SUITE 203
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-9093
Practice Address - Country:US
Practice Address - Phone:502-348-5588
Practice Address - Fax:502-348-1046
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20844208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64208440Medicaid
C75374Medicare UPIN
KYK058820Medicare PIN