Provider Demographics
NPI:1609260660
Name:ANDERSON, ERIC WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WAYNE
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 1:330 W FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3467
Mailing Address - Country:US
Mailing Address - Phone:847-441-4441
Mailing Address - Fax:
Practice Address - Street 1:330 W FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3467
Practice Address - Country:US
Practice Address - Phone:847-441-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.164924208200000X
UT11725384-1205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery