Provider Demographics
NPI:1619955986
Name:ANDERSON, JEROME D (DO)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:D
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:PO BOX 2660
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2660
Mailing Address - Country:US
Mailing Address - Phone:319-233-3044
Mailing Address - Fax:319-233-0722
Practice Address - Street 1:525 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3313
Practice Address - Country:US
Practice Address - Phone:309-837-2368
Practice Address - Fax:319-233-0722
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03039207ZP0101X
IL36075427207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology