Provider Demographics
NPI:1497773238
Name:ANDERSON, DAVID CARLTON (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CARLTON
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 1:1818 E SOUTHERN AVENUE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5228
Mailing Address - Country:US
Mailing Address - Phone:480-827-7979
Mailing Address - Fax:480-654-7173
Practice Address - Street 1:1818 E SOUTHERN AVENUE
Practice Address - Street 2:SUITE 1B
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5228
Practice Address - Country:US
Practice Address - Phone:480-827-7979
Practice Address - Fax:480-654-7173
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25578208600000X
NE12452208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A95546Medicare UPIN
AZ62979Medicare ID - Type Unspecified