Provider Demographics
NPI:1740234509
Name:ANDERSON, JOHN JAMES (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W WISCONSIN ST
Mailing Address - Street 2:STE 4
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2492
Mailing Address - Country:US
Mailing Address - Phone:608-269-4511
Mailing Address - Fax:609-269-8511
Practice Address - Street 1:215 N BLACK RIVER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1529
Practice Address - Country:US
Practice Address - Phone:608-269-4511
Practice Address - Fax:608-269-8511
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3614-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI350052230OtherRAILROAD MEDICARE
WI38993500OtherMEDICAID CLINIC NUMBER
WI38923500Medicaid
WICB3715OtherRAILROAD MEDICARE GROUP
WI38993500OtherMEDICAID CLINIC NUMBER
WI38923500Medicaid