Provider Demographics
NPI:1760482863
Name:ANDERSON, LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-2209
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:SUITE 455
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2161
Practice Address - Country:US
Practice Address - Phone:607-763-8100
Practice Address - Fax:607-763-8048
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1923942086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01415796Medicaid
NY01415796Medicaid
NY52839YMedicare ID - Type Unspecified