Provider Demographics
NPI:1790706430
Name:ANDERSON, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:5006 UNIVERSITY DRIVE, #3
Mailing Address - Street 2:
Mailing Address - City:COLLEGEDALE
Mailing Address - State:TN
Mailing Address - Zip Code:37315-5001
Mailing Address - Country:US
Mailing Address - Phone:503-489-1122
Mailing Address - Fax:503-489-1123
Practice Address - Street 1:10101 SE MAIN ST
Practice Address - Street 2:SUITE 3008
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2455
Practice Address - Country:US
Practice Address - Phone:503-489-1122
Practice Address - Fax:503-489-1123
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC143100207X00000X
TXS0422207X00000X
PAMD450150207X00000X
ORMD26880207X00000X, 207XX0005X
SD10506207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH78126Medicare UPIN
ORH78126Medicare UPIN