Provider Demographics
NPI:1689653750
Name:ANDERSON, JOHN RYAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RYAN
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 1460
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22402-1460
Mailing Address - Country:US
Mailing Address - Phone:540-786-2100
Mailing Address - Fax:540-786-0677
Practice Address - Street 1:12101 CAROL LN
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6101
Practice Address - Country:US
Practice Address - Phone:540-786-7810
Practice Address - Fax:540-786-3099
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101040122OtherLICENSE
VA0897726OtherAETNA HMO
VA4091285OtherAETNA NON HMO
VA82934OtherMAMSI
VA000090765OtherAETNA CAP
VA005654432Medicaid
VA175034OtherANTHEM
VACA9037OtherMCR RAILROAD GROUP
VAC02375OtherMEDICARE GROUP
B08472Medicare UPIN
VA080002116Medicare PIN
VA0897726OtherAETNA HMO