Provider Demographics
NPI:1558350611
Name:ANDERSON, JOHN WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WESLEY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:PMB 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-284-8841
Mailing Address - Fax:503-282-3302
Practice Address - Street 1:9450 SW BARNES RD
Practice Address - Street 2:NUMBER 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6619
Practice Address - Country:US
Practice Address - Phone:503-292-6238
Practice Address - Fax:503-292-0987
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD106182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228049Medicaid
C92095Medicare UPIN
OR228049Medicaid