Provider Demographics
NPI:1710906441
Name:ANDERSON, RICHARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
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 581
Mailing Address - Street 2:
Mailing Address - City:LEVAN
Mailing Address - State:UT
Mailing Address - Zip Code:84639-0581
Mailing Address - Country:US
Mailing Address - Phone:435-843-9964
Mailing Address - Fax:435-843-9907
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-843-9964
Practice Address - Fax:435-843-9907
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181085-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG23039Medicare UPIN