Provider Demographics
NPI:1518055573
Name:ANDERSON, IAN CHURCHILL (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:CHURCHILL
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 1:3555 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1757
Mailing Address - Country:US
Mailing Address - Phone:707-528-1050
Mailing Address - Fax:707-525-3874
Practice Address - Street 1:3555 ROUND BARN CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-528-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49481207RH0000X, 207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A494810Medicaid
00A494810Medicare ID - Type Unspecified
CA00A494810Medicaid