Provider Demographics
NPI:1619941606
Name:ANDERSON, JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
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 1:9695 NW KAISER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97231-2736
Mailing Address - Country:US
Mailing Address - Phone:503-686-1172
Mailing Address - Fax:
Practice Address - Street 1:9695 NW KAISER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97231-2736
Practice Address - Country:US
Practice Address - Phone:503-686-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13822207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR050049894OtherRR MEDICARE
WA8109449Medicaid
OR205518Medicaid
OR106337Medicare PIN
WA8109449Medicaid
OR00WCJPPT5Medicare UPIN