Provider Demographics
NPI:1508072695
Name:ANDERSON, KYLE PRESTON (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:PRESTON
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3615 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1203
Practice Address - Country:US
Practice Address - Phone:806-725-2233
Practice Address - Fax:806-725-0053
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3449207P00000X
LA204058207P00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM985396566Medicaid
TX8DV404OtherBCBS
TX920057100OtherFIRSTCARE
TX295955YKT8Medicare PIN