Provider Demographics
NPI:1588682983
Name:ANDERSON, KEVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 INDUSTRIAL RD
Mailing Address - Street 2:STE 5
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3736
Mailing Address - Country:US
Mailing Address - Phone:508-473-1480
Mailing Address - Fax:508-473-2709
Practice Address - Street 1:200 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:NORTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01534-1425
Practice Address - Country:US
Practice Address - Phone:508-731-2575
Practice Address - Fax:508-266-0608
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2093207R00000X
TXM7826207R00000X
MA273031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11013370AMedicaid