Provider Demographics
NPI:1659338887
Name:ANDERSON, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
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 1:9787 N 91ST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5088
Mailing Address - Country:US
Mailing Address - Phone:480-563-6400
Mailing Address - Fax:480-563-8009
Practice Address - Street 1:9787 N 91ST ST STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5088
Practice Address - Country:US
Practice Address - Phone:480-563-6400
Practice Address - Fax:480-563-8009
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24265207P00000X
AZ45727208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200055660AMedicaid
OK24H619001Medicare PIN
OK243521103Medicare PIN
OK243521104Medicare PIN
OKI28095Medicare UPIN
OK200055660AMedicaid
OK24H620501Medicare PIN
OKOK400794Medicare PIN