Provider Demographics
NPI:1578870622
Name:MEDICAL OFFICES OF DEVRY ANDERSON
Entity Type:Organization
Organization Name:MEDICAL OFFICES OF DEVRY ANDERSON
Other - Org Name:MEDICAL OFFICES OF CENTRAL TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVRY
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-630-9366
Mailing Address - Street 1:1033 S FORT HOOD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-7436
Mailing Address - Country:US
Mailing Address - Phone:254-630-9366
Mailing Address - Fax:254-634-7700
Practice Address - Street 1:1033 S FORT HOOD ST STE 200
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-7436
Practice Address - Country:US
Practice Address - Phone:254-630-9366
Practice Address - Fax:254-634-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3448261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210501701Medicaid
TX210501702Medicaid