Provider Demographics
NPI:1598747909
Name:ANDERSON, WILLIAM STANTON III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:STANTON
Last Name:ANDERSON
Suffix:III
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 1:1501 SAN PEDRO DR SE
Mailing Address - Street 2:# 182-C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:505-256-6414
Practice Address - Street 1:516 EAST NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8740
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC115896Medicaid
SC115896Medicaid
SCD90830Medicare UPIN