Provider Demographics
NPI:1639347073
Name:ANDERSON, DANIER DESELLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:DANIER
Middle Name:DESELLE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8649 HIGHWAY 165 N STE 1
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8965
Mailing Address - Country:US
Mailing Address - Phone:318-283-3980
Mailing Address - Fax:318-239-8980
Practice Address - Street 1:8649 HIGHWAY 165 N STE 1
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8965
Practice Address - Country:US
Practice Address - Phone:318-283-3980
Practice Address - Fax:318-239-8980
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPM.200039213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2319523Medicaid