Provider Demographics
NPI:1598797979
Name:ANDERSON, ROGER ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALLAN
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 1:34719 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8714
Mailing Address - Country:US
Mailing Address - Phone:206-260-2503
Mailing Address - Fax:855-912-9151
Practice Address - Street 1:502 S M ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3728
Practice Address - Country:US
Practice Address - Phone:800-340-3595
Practice Address - Fax:855-929-1515
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054741A207W00000X
WAMD60956447207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2157055Medicaid