Provider Demographics
NPI:1629014824
Name:ANDERSON, CRAIG DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:DOUGLAS
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 1:350 MILLER ST SE # 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4272
Mailing Address - Country:US
Mailing Address - Phone:503-371-4647
Mailing Address - Fax:503-584-7856
Practice Address - Street 1:350 MILLER ST SE # 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-371-4647
Practice Address - Fax:503-584-7856
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20636207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150514Medicaid
F45153Medicare UPIN
OR150514Medicaid