Provider Demographics
NPI:1780670828
Name:ANDERSON, KELLY R (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1038
Mailing Address - Country:US
Mailing Address - Phone:812-885-3685
Mailing Address - Fax:812-885-3917
Practice Address - Street 1:520 S 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-885-3810
Practice Address - Fax:812-885-3811
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001311A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000110680OtherANTHEM
IN200022500Medicaid
IN941140DDMedicare ID - Type Unspecified
INE97987Medicare UPIN