Provider Demographics
NPI:1700381548
Name:ANDERSON, JUSTIN DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DOUGLAS
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 1:13400 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5499
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:4003 KRESGE WAY STE 115
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4652
Practice Address - Country:US
Practice Address - Phone:502-897-8163
Practice Address - Fax:502-928-8919
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR76708207R00000X
390200000X
KYTP5082085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program