Provider Demographics
NPI:1679640866
Name:ANDERSON, MARK DORAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DORAN
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 1:96 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-4069
Mailing Address - Country:US
Mailing Address - Phone:203-438-0874
Mailing Address - Fax:203-438-5986
Practice Address - Street 1:96 DANBURY RD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4069
Practice Address - Country:US
Practice Address - Phone:203-438-0874
Practice Address - Fax:203-438-5986
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT027066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010027066CT01OtherBCBS-CT
CTZP138OtherOXFORD HEALTH PLANS
CT774197OtherCONNECTICARE
CT1237318OtherAETNA
CT001270669Medicaid
CT110001244Medicare ID - Type Unspecified
CT001270669Medicaid