Provider Demographics
NPI:1578512901
Name:ANDERSON, PAUL JACKSON JR (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JACKSON
Last Name:ANDERSON
Suffix:JR
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:PO BOX 1345
Mailing Address - Street 2:
Mailing Address - City:POINT CLEAR
Mailing Address - State:AL
Mailing Address - Zip Code:36564-1345
Mailing Address - Country:US
Mailing Address - Phone:251-928-9281
Mailing Address - Fax:251-928-9281
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:MASTIN BLDG. 617
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-470-5842
Practice Address - Fax:251-470-5809
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL16-01418OtherUNITED HEALTHCARE
AL51530385OtherBCBS
MS06029094Medicaid
C76015Medicare UPIN