Provider Demographics
NPI:1790760494
Name:ANDERSON, CHRISTOPHER JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JAMES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 INSIGHT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-277-9533
Mailing Address - Fax:618-277-9540
Practice Address - Street 1:717 INSIGHT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-277-9533
Practice Address - Fax:618-277-9540
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010030718213ES0131X
IL016.005443213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU92226Medicare UPIN
ILIL7602001Medicare PIN
IL6815910001Medicare NSC