Provider Demographics
NPI:1568468171
Name:ANDERSON, DEREK JAMES (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:BLDG 200
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:225-237-1754
Mailing Address - Fax:225-237-1722
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5487
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10793R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA990008020OtherRAILROAD MEDICARE PIN
LA1996254Medicaid
MS00876731Medicaid
LA080179869OtherRAILROAD MEDICARE PIN
LA270663YJGUOtherMEDICARE PTAN
LA270663YJGUOtherMEDICARE PTAN
LA5U730D409Medicare PIN
LA5U730C822Medicare PIN
F89100Medicare UPIN
LA1996254Medicaid
LA270663YH3VMedicare PIN