Provider Demographics
NPI:1629296686
Name:ANDERSON, DALE P (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:P
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:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:2501 BUENA VISTA DR SE
Practice Address - Street 2:PROVIDER ENROLLMENT
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4260
Practice Address - Country:US
Practice Address - Phone:505-923-5356
Practice Address - Fax:505-923-5354
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-130207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPENDINGMedicaid
NMPENDINGMedicaid
NMPENDINGMedicare ID - Type Unspecified