Provider Demographics
NPI:1538119326
Name:ANDERSON, STANLEY R (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:R
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 1:7072 MEARS GATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8850
Mailing Address - Country:US
Mailing Address - Phone:330-966-1319
Mailing Address - Fax:330-966-1321
Practice Address - Street 1:7072 MEARS GATE DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8850
Practice Address - Country:US
Practice Address - Phone:330-966-1319
Practice Address - Fax:330-966-1321
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0684344Medicaid
OHA17416Medicare UPIN
0615294Medicare PIN