Provider Demographics
NPI:1720192925
Name:ANDERSON, WILLIAM J (M D)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:M D
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 102846
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2846
Mailing Address - Country:US
Mailing Address - Phone:404-501-7925
Mailing Address - Fax:404-501-6638
Practice Address - Street 1:4120 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3130
Practice Address - Country:US
Practice Address - Phone:770-935-9546
Practice Address - Fax:770-923-1839
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00641968DMedicaid
GAA99668Medicare UPIN
GA08BDHNKMedicare ID - Type Unspecified