Provider Demographics
NPI:1639185630
Name:ANDERSON, JEFFREY LEE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
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 1809
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-0809
Mailing Address - Country:US
Mailing Address - Phone:714-560-1580
Mailing Address - Fax:714-560-1585
Practice Address - Street 1:1650 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3400
Practice Address - Country:US
Practice Address - Phone:916-983-7461
Practice Address - Fax:916-983-7569
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG058154207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581540Medicaid
CA00G581540OtherBLUE SHIELD
CA00G581540Medicaid
CA00G581540OtherBLUE SHIELD
CAAR580ZMedicare PIN