Provider Demographics
NPI:1659374346
Name:ANDERSON, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
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 1:11001 N BLACK CANYON HWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4757
Mailing Address - Country:US
Mailing Address - Phone:602-371-2515
Mailing Address - Fax:602-371-2002
Practice Address - Street 1:1717 W CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6145
Practice Address - Country:US
Practice Address - Phone:480-821-7565
Practice Address - Fax:480-821-4303
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-05-10
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
AZ24524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0855130OtherBCBS ID
AZ359556Medicaid
AZAZ0855130OtherBCBS ID
29492Medicare ID - Type Unspecified